1962877530 NPI number — EXCELSIOR COMMUNITY SERVICES, 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 1962877530 NPI number — EXCELSIOR COMMUNITY SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXCELSIOR COMMUNITY 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:
1962877530
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 CENTURY 21 DR
Provider Second Line Business Mailing Address:
STE 109B
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32216-8115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-619-1972
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 CENTURY 21 DR
Provider Second Line Business Practice Location Address:
STE 109B
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-8115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-619-1972
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/08/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MCKENZIE
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER/CEO
Authorized Official Telephone Number:
904-559-5975

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 016492600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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