1780650879 NPI number — FLORIDA DEPARTMENT OF HEALTH

Table of content: (NPI 1780650879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780650879 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:
1780650879
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 K D REVELL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUCHULA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33873-2051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-773-4161
Provider Business Mailing Address Fax Number:
863-773-0978

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 K D REVELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUCHULA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33873
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-773-4161
Provider Business Practice Location Address Fax Number:
863-773-0978
Provider Enumeration Date:
02/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MISHOE
Authorized Official First Name:
EVELYN
Authorized Official Middle Name:
DELILAH
Authorized Official Title or Position:
FISCAL ASSISTANT II
Authorized Official Telephone Number:
863-473-6073

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X , 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: CH8202 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 027935800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 027935804 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 99130 . This is a "BC/BS GROUP NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 027935830 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 027935803 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 027935801 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 027935802 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 027935809 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 027935800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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