Provider Demographics
NPI:1750369666
Name:SMA HEALTHCARE INC
Entity type:Organization
Organization Name:SMA HEALTHCARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
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:386-236-3175
Practice Address - Street 1:1150 RED JOHN DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32124-1016
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:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL407251S00000X
261QM0801X, 283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060311221Medicaid
FL0603112220Medicaid