1396250098 NPI number — ADVANCED KID'S CARE

Table of content: (NPI 1396250098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396250098 NPI number — ADVANCED KID'S CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED KID'S CARE
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:
1396250098
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5049 LATROBE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINDERMERE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34786-8914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-819-6804
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
98 TERRA MANGO LOOP
Provider Second Line Business Practice Location Address:
UNIT 12
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-819-7137
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/05/2017

Additional Information

Authorized Official

Authorized Official Last Name:
ANTONYRAJAH
Authorized Official First Name:
BERNADETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
419-819-7137

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  ME113681 , 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: 3108461 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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