1396326807 NPI number — COTG 2021

Table of content: (NPI 1396326807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396326807 NPI number — COTG 2021

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COTG 2021
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:
COVID ON THE GO
Provider Other Organization Name Type Code:
3
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:
1396326807
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1220 PROSPECT AVE STE 294
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32901-7300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-300-6531
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1385 CYPRESS AVE UNIT 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32935-5919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-327-7481
Provider Business Practice Location Address Fax Number:
888-453-1715
Provider Enumeration Date:
04/16/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PRINCE
Authorized Official First Name:
FELICIA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
321-327-7481

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QC1500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QX0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 114702700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".