Healthcare Provider Details

I. General information

NPI: 1912308966
Provider Name (Legal Business Name): SEGULAH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2014
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2107 COUNTRY SIDE DR
APOPKA FL
32712-2069
US

IV. Provider business mailing address

2107 COUNTRY SIDE DR
APOPKA FL
32712-2069
US

V. Phone/Fax

Practice location:
  • Phone: 321-229-4168
  • Fax: 407-814-3153
Mailing address:
  • Phone: 321-229-4168
  • Fax: 407-814-3153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberPT5636
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License NumberPT5636
License Number StateFL

VIII. Authorized Official

Name: ERNESTO MARIQUIT
Title or Position: OWNER/PRESIDENT
Credential: RPT
Phone: 321-229-4168