MEDICARE: HIPPODROME STATE THEATRE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	0301AD068701	FL

General Provider Information

NPI Number	:	1558365833
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIPPODROME STATE THEATRE

Provider Business Mailing Address
First Line	:	25 SE 2ND PL
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32601-6567
Country	:	US
Telephone Number	:	352-373-5968
Fax Number	:	352-371-9130

Provider Business Practice Location Address
First Line	:	25 SE 2ND PL
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32601-6567
Country	:	US
Telephone Number	:	352-373-5968
Fax Number	:	352-371-9130

Authorized Official
Title or Position	:	PRODUCING DIRECTOR
Name	:	MS. MARY HAUSCH
Credential	:
Telephone Number	:	352-373-5968

Provider Enumeration Date	:	06/02/2005
Last Update Date	:	08/22/2020

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