1821406000 NPI number — SPIRES BEHAVIORAL HEALTH CARE CENTER, PLLC

Table of content: (NPI 1821406000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821406000 NPI number — SPIRES BEHAVIORAL HEALTH CARE CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPIRES BEHAVIORAL HEALTH CARE CENTER, PLLC
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:
1821406000
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5728
Provider Second Line Business Mailing Address:
4428 LAFAYETTE STREET
Provider Business Mailing Address City Name:
MARIANNA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32447-5728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-482-4177
Provider Business Mailing Address Fax Number:
850-482-4178

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4428 LAFAYETTE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIANNA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32447-5728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-482-4177
Provider Business Practice Location Address Fax Number:
850-482-4178
Provider Enumeration Date:
07/31/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SPIRES
Authorized Official First Name:
WILLIE
Authorized Official Middle Name:
EARL
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
850-482-4177

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MH0026 , 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: 600562012 . This is a "MAGELLAN BEHAVIORAL HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 000258100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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