1699241703 NPI number — COMPREHENSIVE HEALTH X4

Table of content: (NPI 1699241703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699241703 NPI number — COMPREHENSIVE HEALTH X4

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPREHENSIVE HEALTH X4
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:
1699241703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1069 S. CLARKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCOEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34761
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
483 N SEMORAN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTER PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32792-3800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-434-9212
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/16/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NAUGHTIN
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
407-434-9212

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1447595384 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1427596402 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1376968586 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".