1285621987 NPI number — SOVEREIGN HEALTHCARE OF ORANGE CITY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285621987 NPI number — SOVEREIGN HEALTHCARE OF ORANGE CITY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOVEREIGN HEALTHCARE OF ORANGE CITY, 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:
1285621987
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5887 GLENRIDGE DR
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30328-5574
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-574-2100
Provider Business Mailing Address Fax Number:
404-574-2105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2810 ENTERPRISE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEBARY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32713-2703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-668-8818
Provider Business Practice Location Address Fax Number:
386-668-6510
Provider Enumeration Date:
09/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CRONQUIST
Authorized Official First Name:
R.
Authorized Official Middle Name:
MARK
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
404-574-2100

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  SNF1464096 , 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: 026356700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: V573P-6387 . This is a "VA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 026356700 . 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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