1699955617 NPI number — AMMALA CANTRELL

Table of content: (NPI 1699955617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699955617 NPI number — AMMALA CANTRELL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMMALA CANTRELL
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:
1699955617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 50670
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32240-0670
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-372-0208
Provider Business Mailing Address Fax Number:
904-853-6559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1370 13TH AVE S
Provider Second Line Business Practice Location Address:
SUITE 216A
Provider Business Practice Location Address City Name:
JACKSONVILLE BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32250-3230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-372-0208
Provider Business Practice Location Address Fax Number:
904-853-6559
Provider Enumeration Date:
11/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CANTRELL
Authorized Official First Name:
AMMALA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
904-673-5553

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME84833 , 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: K8204 . This is a "BC/BS OF FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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