1679704878 NPI number — TRI-COUNTY INFECTIOUS DISEASE

Table of content: (NPI 1679704878)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679704878 NPI number — TRI-COUNTY INFECTIOUS DISEASE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-COUNTY INFECTIOUS DISEASE
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:
1679704878
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1576 BELLA CRUZ DRIVE
Provider Second Line Business Mailing Address:
SUITE 336
Provider Business Mailing Address City Name:
THE VILLAGES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32159-8969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-633-0215
Provider Business Mailing Address Fax Number:
352-633-0219

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 OLD CAMP RD
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
THE VILLAGES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32162-5609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-633-0215
Provider Business Practice Location Address Fax Number:
352-633-0219
Provider Enumeration Date:
08/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GILLIKIN
Authorized Official First Name:
SHEILA
Authorized Official Middle Name:
Authorized Official Title or Position:
OPERATIONS MANAGER
Authorized Official Telephone Number:
352-633-0215

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001364700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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