1518634054 NPI number — DAVENPORT BEHAVIORAL CENTER LLC

Table of content: (NPI 1518634054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518634054 NPI number — DAVENPORT BEHAVIORAL CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVENPORT BEHAVIORAL CENTER 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:
1518634054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 AMBERSWEET WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVENPORT
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33897-8418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-663-6375
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19 N 6TH STREET
Provider Second Line Business Practice Location Address:
19A
Provider Business Practice Location Address City Name:
HAINES CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-663-6375
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2021

Additional Information

Authorized Official

Authorized Official Last Name:
CRUZ
Authorized Official First Name:
FRAINELYS
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER
Authorized Official Telephone Number:
321-278-4084

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 112416500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com