Provider Demographics
NPI:1891257697
Name:BA SKINNER GROUP INC.
Entity type:Organization
Organization Name:BA SKINNER GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRTESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-566-8565
Mailing Address - Street 1:1575 AVIATION CENTER PKWY STE 525
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-3864
Mailing Address - Country:US
Mailing Address - Phone:386-566-8565
Mailing Address - Fax:
Practice Address - Street 1:1575 AVIATION CENTER PKWY STE 525
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-3864
Practice Address - Country:US
Practice Address - Phone:386-566-8565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101920900Medicaid