Provider Demographics
NPI:1275771560
Name:APD - TACACHALE
Entity Type:Organization
Organization Name:APD - TACACHALE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DON
Authorized Official - Middle Name:E
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-955-5856
Mailing Address - Street 1:1621 NE WALDO RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32609-3900
Mailing Address - Country:US
Mailing Address - Phone:352-955-5668
Mailing Address - Fax:
Practice Address - Street 1:1621 NE WALDO RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-3900
Practice Address - Country:US
Practice Address - Phone:352-955-5616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-26
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN8807122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL681084596Medicaid