Basic Information
| Provider Information | |||||||||
| NPI: | 1922369792 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNITED CEREBRAL PALSY OF EAST CENTRAL FLORIDA, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UCP/WORC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 JIMMY ANN DR | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321173920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862746474 | ||||||||
| FaxNumber: | 3862746532 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 JIMMY ANN DR | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321173920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862746474 | ||||||||
| FaxNumber: | 3862746532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2012 | ||||||||
| LastUpdateDate: | 06/07/2012 | ||||||||
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| AuthorizedOfficialLastName: | BYRD | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3862746474 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | Y | Agencies | Day Training, Developmentally Disabled Services |
ID Information
| ID | Type | State | Issuer | Description | 023962396 | 05 | FL | MEDICAID |