Provider Demographics
NPI:1356329163
Name:SMA HEALTHCARE INC
Entity Type:Organization
Organization Name:SMA HEALTHCARE INC
Other - Org Name:ACT CORPORATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:COSIMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-236-1811
Mailing Address - Street 1:150 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-4304
Mailing Address - Country:US
Mailing Address - Phone:386-236-3225
Mailing Address - Fax:386-236-3178
Practice Address - Street 1:1220 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2810
Practice Address - Country:US
Practice Address - Phone:386-236-3225
Practice Address - Fax:386-236-3175
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SMA HEALTHCARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-03
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060311200Medicaid
FL270196100Medicaid
FL004471200Medicaid
FL060311211Medicaid
FL060311200Medicaid
FL060311210Medicaid
FL060311226Medicaid
FL060311206Medicaid
FL060311215Medicaid