1518634054 NPI number — DAVENPORT BEHAVIORAL CENTER 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 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".




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