1932781705 NPI number — SUNCOAST NEW OPTIONS 35TH PLACE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932781705 NPI number — SUNCOAST NEW OPTIONS 35TH PLACE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNCOAST NEW OPTIONS 35TH PLACE, 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:
1932781705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6531 MERIDIEN DR STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27616-3213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3423 SE 35TH PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32641-9392
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-390-2980
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/22/2021

Additional Information

Authorized Official

Authorized Official Last Name:
BENSON
Authorized Official First Name:
MARY
Authorized Official Middle Name:
JOHNS
Authorized Official Title or Position:
DIRECTOR OF BILLING
Authorized Official Telephone Number:
336-553-5946

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 012375400 . 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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