Healthcare Provider Details

I. General information

NPI: 1568381465
Provider Name (Legal Business Name): BJK PROVIDER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 ANHINGA ST
CANTONMENT FL
32533-9348
US

IV. Provider business mailing address

127 ANHINGA ST
CANTONMENT FL
32533-9348
US

V. Phone/Fax

Practice location:
  • Phone: 850-287-2066
  • Fax: 850-285-0849
Mailing address:
  • Phone: 850-287-2066
  • Fax: 850-285-0849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. BARBARA GORAM
Title or Position: MANAGER/PROVIDER
Credential:
Phone: 850-287-2066