Basic Information
| Provider Information | |||||||||
| NPI: | 1073710109 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTER SEALS FLORIDA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2010 CROSBY WAY | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327924119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076297881 | ||||||||
| FaxNumber: | 4076294754 | ||||||||
| Practice Location | |||||||||
| Address1: | 213 S CONGRESS AVE | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334093823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618812822 | ||||||||
| FaxNumber: | 5618810972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2007 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | BLAKE | ||||||||
| AuthorizedOfficialFirstName: | RIKESHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4076297881 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EASTER SEALS FLORIDA, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | N | Agencies | Home Health | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 892255100 | 05 | FL | MEDICAID | 914570200 | 05 | FL | MEDICAID |