Basic Information
| Provider Information | |||||||||
| NPI: | 1013269851 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMPREHENSIVE CARE CENTER INC NORTH PORT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY AIDS NETWORK, NORTH PORT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 14243 TAMIAMI TRL | ||||||||
| Address2: | |||||||||
| City: | NORTH PORT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342872215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413660134 | ||||||||
| FaxNumber: | 9419511795 | ||||||||
| Practice Location | |||||||||
| Address1: | 1231 N TUTTLE AVE | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342373116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413660134 | ||||||||
| FaxNumber: | 9419511795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2012 | ||||||||
| LastUpdateDate: | 10/03/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CUFFAGE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9413660134 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMPREHENSIVE CARE CENTER INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
| ID | Type | State | Issuer | Description | 057256000 | 05 | FL | MEDICAID |