Provider Demographics
NPI:1497428080
Name:SMA HEALTHCARE INC
Entity Type:Organization
Organization Name:SMA HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
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:386-236-3215
Mailing Address - Fax:
Practice Address - Street 1:105 W CALVIN ST
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-7403
Practice Address - Country:US
Practice Address - Phone:800-539-4228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SMA HEALTHCARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060311213Medicaid