Basic Information
| Provider Information | |||||||||
| NPI: | 1053972760 | ||||||||
| 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: | 06/24/2019 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HENGESBACH | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | JUSTIN | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8634192260 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | N | Hospital Units | Psychiatric Unit | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.