MEDICARE: TALLAHASSEE DEVELOPMENTAL CENTER

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	310500000X	Mental Illness Intermediate Care Facility	4096096	FL

General Provider Information

NPI Number	:	1609875160
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TALLAHASSEE DEVELOPMENTAL CENTER

Provider Business Mailing Address
First Line	:	455 APPLEYARD DR
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32304-2808
Country	:	US
Telephone Number	:	850-575-0619
Fax Number	:	850-576-5773

Provider Business Practice Location Address
First Line	:	455 APPLEYARD DR
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32304-2808
Country	:	US
Telephone Number	:	850-575-0619
Fax Number	:	850-576-5773

Authorized Official
Title or Position	:	PROGRAM SERVICES DIRECTOR
Name	:	MR. FRED JIMINEZ
Credential	:
Telephone Number	:	850-575-0619

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	08/22/2020

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