1922523497 NPI number — FLORIDA AGING MENTAL HEALTH LLC

Table of content: (NPI 1922523497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922523497 NPI number — FLORIDA AGING MENTAL HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA AGING MENTAL HEALTH 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:
1922523497
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10210 MARSH HARBOR WAY APT 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERVIEW
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33578
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-208-0284
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5827 OAK BRIDGE CT
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:
34211-1734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-208-0284
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/07/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WILCOX
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
LCSW CONSULTANT
Authorized Official Telephone Number:
352-208-0284

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  14000 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)