MEDICARE: EASTERSEALS NORTHEAST CENTRAL FLORIDA, INC.

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1689448987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTERSEALS NORTHEAST CENTRAL FLORIDA, INC.

Provider Business Mailing Address
First Line	:	1219 DUNN AVE
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-2405
Country	:	US
Telephone Number	:	386-255-4568
Fax Number	:	386-258-7677

Provider Business Practice Location Address
First Line	:	3389 N STATE ST UNIT 1
Second Line	:
City	:	BUNNELL
State	:	FL
Zip	:	32110-4340
Country	:	US
Telephone Number	:	386-255-4568
Fax Number	:	386-258-7677

Authorized Official
Title or Position	:	ACCOUNTING MANAGER
Name	:	MICHELE WALLENS
Credential	:
Telephone Number	:	386-255-4568

Provider Enumeration Date	:	11/08/2023
Last Update Date	:	11/08/2023

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