1497407977 NPI number — NEW PORT RICHEY OPCO, 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 1497407977 NPI number — NEW PORT RICHEY OPCO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW PORT RICHEY OPCO, 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:
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:
1497407977
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8417 OLD COUNTY ROAD 54
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW PORT RICHEY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34653-6418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-376-1585
Provider Business Mailing Address Fax Number:
727-372-7085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8417 OLD COUNTY ROAD 54
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW PORT RICHEY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34653-6418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-376-1585
Provider Business Practice Location Address Fax Number:
727-372-7085
Provider Enumeration Date:
01/25/2022

Additional Information

Authorized Official

Authorized Official Last Name:
VARGHESE
Authorized Official First Name:
MATHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
917-817-3530

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1429096 . This is a "LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 008039700 . 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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