1720536527 NPI number — SPRING HILL WELLNESS LLC

Table of content: (NPI 1720536527)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720536527 NPI number — SPRING HILL WELLNESS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRING HILL WELLNESS 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:
SPRING GARDENS DETOX
Provider Other Organization Name Type Code:
3
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:
1720536527
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 BROADWAY
Provider Second Line Business Mailing Address:
SUITE 602
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11249-8663
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:
8213 CESSNA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRING HILL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34606-3024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-244-9556
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/21/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROSENBAUM
Authorized Official First Name:
SHIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
917-301-5254

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , 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: 112393700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".