1144907429 NPI number — DIVERSITY HEALTHCARE 'LLC'

Table of content: (NPI 1144907429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144907429 NPI number — DIVERSITY HEALTHCARE 'LLC'

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVERSITY HEALTHCARE 'LLC'
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144907429
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1011 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAINES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33844
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-419-4422
Provider Business Mailing Address Fax Number:
833-795-1975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1011 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAINES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-419-4422
Provider Business Practice Location Address Fax Number:
833-795-1975
Provider Enumeration Date:
06/29/2023

Additional Information

Authorized Official

Authorized Official Last Name:
REEDY
Authorized Official First Name:
CLAYTON
Authorized Official Middle Name:
DALE
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
863-419-4422

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LA2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 119946400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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