Basic Information
| Provider Information | |||||||||
| NPI: | 1720337348 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OUR CHILDREN'S MIDDLE ACADEMY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 AVENUE B, SE | ||||||||
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| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33880 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 150 AVENUE B, SE | ||||||||
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| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632941429 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2012 | ||||||||
| LastUpdateDate: | 08/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | REMOR | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 8632941429 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225XP0200X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.