1679548861 NPI number — FLORIDA DEPARTMENT OF HEALTH

Table of content: (NPI 1679548861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679548861 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:
1679548861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1305
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAVARES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32778-1305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-589-6424
Provider Business Mailing Address Fax Number:
352-589-6492

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16140 US HWY 441
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUSTIS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32726-1305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-589-6424
Provider Business Practice Location Address Fax Number:
352-589-6492
Provider Enumeration Date:
02/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KISSLER
Authorized Official First Name:
AARON
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
352-589-6424

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 056323400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com