1659416949 NPI number — RIVERSIDE GLADES MEDICAL CENTER

Table of content: (NPI 1659416949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659416949 NPI number — RIVERSIDE GLADES MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE GLADES MEDICAL CENTER
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:
1659416949
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1332
Provider Second Line Business Mailing Address:
51 AVE J
Provider Business Mailing Address City Name:
MOORE HAVEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33471-1332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-946-1000
Provider Business Mailing Address Fax Number:
863-946-1110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51 AVENUE J SW
Provider Second Line Business Practice Location Address:
-MAIL NOT DELIVERED TO THIS RURAL ADDRESS
Provider Business Practice Location Address City Name:
MOORE HAVEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33471-1332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-946-1000
Provider Business Practice Location Address Fax Number:
863-946-1110
Provider Enumeration Date:
02/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GEAKE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
DONALD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
863-946-1000

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  OS7165 , 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: OS7165 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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