Provider Demographics
NPI:1275834129
Name:PRISON REHABILITATIVE INDUSTRIES & DIVERSIFIED ENTERPRISES
Entity Type:Organization
Organization Name:PRISON REHABILITATIVE INDUSTRIES & DIVERSIFIED ENTERPRISES
Other - Org Name:PRIDE ENTERPRISES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY TO THE BOARD
Authorized Official - Prefix:MISS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMINKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-556-3300
Mailing Address - Street 1:12425 28TH ST N
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1844
Mailing Address - Country:US
Mailing Address - Phone:727-556-3300
Mailing Address - Fax:727-570-3449
Practice Address - Street 1:12425 28TH ST. N.
Practice Address - Street 2:SUITE 300
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716
Practice Address - Country:US
Practice Address - Phone:727-556-3300
Practice Address - Fax:727-570-3449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory