1245571181 NPI number — DISC VILLAGE, INC.

Table of content: (NPI 1245571181)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245571181 NPI number — DISC VILLAGE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DISC VILLAGE, INC.
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:
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:
1245571181
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3333 W PENSACOLA ST
Provider Second Line Business Mailing Address:
SUITE 330
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32304-2888
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-575-4388
Provider Business Mailing Address Fax Number:
850-576-3317

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 W THARPE ST
Provider Second Line Business Practice Location Address:
SUITE 16
Provider Business Practice Location Address City Name:
TALLAHASSEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32303-5374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-487-0432
Provider Business Practice Location Address Fax Number:
850-487-0431
Provider Enumeration Date:
03/01/2013

Additional Information

Authorized Official

Authorized Official Last Name:
SKIPTON
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
QA DIRECTOR
Authorized Official Telephone Number:
850-766-1251

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  0237AD133807 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 060600625 . 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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