1548263114 NPI number — FLORIDA DEPARTMENT OF HEALTH

Table of content: (NPI 1548263114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548263114 NPI number — FLORIDA DEPARTMENT OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA DEPARTMENT OF HEALTH
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:
6
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:
1548263114
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12832 NW CENTRAL AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRISTOL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32321-0489
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-643-2292
Provider Business Mailing Address Fax Number:
850-643-2306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10971 NW SPRING STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32321-0489
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-643-2292
Provider Business Practice Location Address Fax Number:
850-643-2306
Provider Enumeration Date:
05/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KING
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OMC MANAGER
Authorized Official Telephone Number:
850-643-2415

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X , 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: 027949891 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 027949803 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 027949805 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 027949808 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 027949802 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 027949800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 027949807 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10-1820 . This is a "MEDICARE FQHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 027949804 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 027949830 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 72156 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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