Basic Information
| Provider Information | |||||||||
| NPI: | 1982886685 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLORIDA MENTOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2055 WOOD ST | ||||||||
| Address2: | SUITE 118 | ||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342377903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419552593 | ||||||||
| FaxNumber: | 9419552684 | ||||||||
| Practice Location | |||||||||
| Address1: | 2055 WOOD ST | ||||||||
| Address2: | SUITE 118 | ||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342377903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419552593 | ||||||||
| FaxNumber: | 9419552684 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2007 | ||||||||
| LastUpdateDate: | 12/04/2007 | ||||||||
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| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | STATE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3055980242 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.