1568783660 NPI number — SHADY ACRES, INC.

Table of content: (NPI 1568783660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568783660 NPI number — SHADY ACRES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHADY ACRES, INC.
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:
1568783660
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
670 CR 782
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEBSTER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33597-3512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-568-0058
Provider Business Mailing Address Fax Number:
352-568-0082

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
670 CR 782
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEBSTER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33597-3512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-568-0058
Provider Business Practice Location Address Fax Number:
352-568-0082
Provider Enumeration Date:
06/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LONG
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
352-303-2827

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL9373 , 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: 676605600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 140787200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com