MEDICARE: PENSACOLA 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	4058096	FL

General Provider Information

NPI Number	:	1841299450
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENSACOLA DEVELOPMENTAL CENTER

Provider Business Mailing Address
First Line	:	1 VILLA DR
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32506-5535
Country	:	US
Telephone Number	:	850-453-2323
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 VILLA DR
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32506-5535
Country	:	US
Telephone Number	:	850-453-2323
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. WAYNE DANIELS
Credential	:
Telephone Number	:	850-453-2323

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	08/22/2020

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