1871979575 NPI number — SUGARS SUPPORTIVE SERVICES, LLC

Table of content: (NPI 1871979575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871979575 NPI number — SUGARS SUPPORTIVE SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUGARS SUPPORTIVE SERVICES, LLC
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:
1871979575
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2204 CITRUS BLVD
Provider Second Line Business Mailing Address:
SUITE 10B
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34748-3019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-435-4600
Provider Business Mailing Address Fax Number:
352-435-4605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2204 CITRUS BLVD
Provider Second Line Business Practice Location Address:
SUITE 10B
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34748-3019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-435-4600
Provider Business Practice Location Address Fax Number:
352-435-4605
Provider Enumeration Date:
08/04/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CALDWELL
Authorized Official First Name:
LORRAINE
Authorized Official Middle Name:
ADELE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
352-617-0400

Provider Taxonomy Codes

  • Taxonomy code: 172V00000X , with the licence number:  001917900 , 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: 690259696 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001917900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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