1295069672 NPI number — SRA VENTURES INC

Table of content: (NPI 1295069672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295069672 NPI number — SRA VENTURES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SRA VENTURES 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:
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:
1295069672
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 S LINCOLN AVE
Provider Second Line Business Mailing Address:
#15
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33756-5945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-446-6760
Provider Business Mailing Address Fax Number:
727-441-2465

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2040 SHORT AVE
Provider Second Line Business Practice Location Address:
#103
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33556-3445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-835-1450
Provider Business Practice Location Address Fax Number:
727-835-1470
Provider Enumeration Date:
10/01/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ABOUD
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
Authorized Official Title or Position:
C.E.O.
Authorized Official Telephone Number:
727-835-1450

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: E4187 . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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