1568079069 NPI number — BENEVOLENT HEART LLC

Table of content: (NPI 1568079069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568079069 NPI number — BENEVOLENT HEART LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BENEVOLENT HEART 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:
1568079069
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 43711
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32203-3711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-638-1739
Provider Business Mailing Address Fax Number:
866-728-4298

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13366 OCEAN MIST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32258-5204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-638-1739
Provider Business Practice Location Address Fax Number:
866-728-4298
Provider Enumeration Date:
09/28/2020

Additional Information

Authorized Official

Authorized Official Last Name:
MILLS
Authorized Official First Name:
WHITNEY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/ADMINISTRATOR
Authorized Official Telephone Number:
904-638-1739

Provider Taxonomy Codes

  • Taxonomy code: 251J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 101166300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com