Healthcare Provider Details

I. General information

NPI: 1235643693
Provider Name (Legal Business Name): PATHFINDER ADVOCACY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2017
Last Update Date: 11/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4750 E MOODY BLVD STE 208
BUNNELL FL
32110-7711
US

IV. Provider business mailing address

4750 E MOODY BLVD STE 208
BUNNELL FL
32110-7711
US

V. Phone/Fax

Practice location:
  • Phone: 386-960-7830
  • Fax: 386-960-7833
Mailing address:
  • Phone: 386-960-7830
  • Fax: 386-960-7833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. VIRGINIA LATIMER
Title or Position: CEO
Credential: CARN
Phone: 386-960-7830