Basic Information
Provider Information | |||||||||
NPI: | 1033770284 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADVENTHEALTH POLK SOUTH INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ADVENTHEALTH LAKE WALES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 410 S 11TH ST | ||||||||
Address2: |   | ||||||||
City: | LAKE WALES | ||||||||
State: | FL | ||||||||
PostalCode: | 338534203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8636761433 | ||||||||
FaxNumber: | 8632971867 | ||||||||
Practice Location | |||||||||
Address1: | 410 S 11TH ST | ||||||||
Address2: |   | ||||||||
City: | LAKE WALES | ||||||||
State: | FL | ||||||||
PostalCode: | 338534203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8636761433 | ||||||||
FaxNumber: | 8632971867 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2019 | ||||||||
LastUpdateDate: | 05/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HENGESBACH | ||||||||
AuthorizedOfficialFirstName: | ALAN | ||||||||
AuthorizedOfficialMiddleName: | JUSTIN | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 8634192260 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ADVENTHEALTH POLK SOUTH INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X |   |   | Y |   | Hospital Units | Psychiatric Unit |   |
No ID Information.