1346296118 NPI number — SOUTH DAYTONA HEALTH CARE ASSOCIATES LLC

Table of content: (NPI 1346296118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346296118 NPI number — SOUTH DAYTONA HEALTH CARE ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH DAYTONA HEALTH CARE ASSOCIATES 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:
1346296118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
650 REED CANAL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH DAYTONA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32119-3230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-767-4831
Provider Business Mailing Address Fax Number:
386-767-8253

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
650 REED CANAL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH DAYTONA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32119-3230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-767-4831
Provider Business Practice Location Address Fax Number:
386-767-8253
Provider Enumeration Date:
05/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FREDSALL
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
386-767-4831

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  SNF1122096 , 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: 025247600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com