Basic Information
| Provider Information | |||||||||
| NPI: | 1538533286 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNITED CEREBRAL PALSY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1221 W COLONIAL DR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328047163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078523347 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1221 W COLONIAL DR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328047163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078523347 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2015 | ||||||||
| LastUpdateDate: | 11/18/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JUDY | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTACT PERSON | ||||||||
| AuthorizedOfficialTelephone: | 4078523347 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251V00000X | 251V00000X | FL | Y | Agencies | Voluntary or Charitable |
ID Information
| ID | Type | State | Issuer | Description | 880020100 | 05 | FL | MEDICAID |