1700821097 NPI number — CENTERWELL HEALTH SERVICES CERTIFIED, INC.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700821097 NPI number — CENTERWELL HEALTH SERVICES CERTIFIED, INC.

Employer Identification Number (EIN):

Provider Organization Name:

CENTERWELL HEALTH SERVICES CERTIFIED, INC.

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

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:

1700821097

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

10/11/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

6330 SPRINT PKWY STE 300

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

OVERLAND PARK

Provider Business Mailing Address State Name:

KS

Provider Business Mailing Address Postal Code:

66211-1157

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

5265 OFFICE PARK BLVD STE 101

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

BRADENTON

Provider Business Practice Location Address State Name:

FL

Provider Business Practice Location Address Postal Code:

34203-3441

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

941-749-2990

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

06/19/2006

Authorized Official Last Name:

NICHOLS

Authorized Official First Name:

JOHN

Authorized Official Middle Name:

Authorized Official Title or Position:

AUTHORIZED SIGNATORY

Authorized Official Telephone Number:

941-749-2990

• Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 1013513 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 115712 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 235397 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 321563003 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 6000055 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 080053 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 2117419 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 689825 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 00011327202 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 11-3414024 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 112645333 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 146544 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 249710 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 095190 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 2307500 . This is a "G2" identifier . This identifiers is of the category "OTHER".