1265751762 NPI number — ST JOHNS YOUTH ACADEMY

Table of content: (NPI 1265751762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265751762 NPI number — ST JOHNS YOUTH ACADEMY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST JOHNS YOUTH ACADEMY
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:
1265751762
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4500 AVENUE D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32095-5245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-829-8850
Provider Business Mailing Address Fax Number:
904-829-8851

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4500 AVENUE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32095-5245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-829-8850
Provider Business Practice Location Address Fax Number:
904-829-8851
Provider Enumeration Date:
05/24/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GRAYSON
Authorized Official First Name:
BARIKA
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
904-829-8850

Provider Taxonomy Codes

  • Taxonomy code: 3245S0500X , with the licence number:  0755AD5690-09 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 322D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0755AD5690-09 . This is a "SUBSTANCE ABUSE LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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