Healthcare Provider Details

I. General information

NPI: 1619943677
Provider Name (Legal Business Name): CMS DAYTONA BEACH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 SOUTH KEECH ST
DAYTONA BEACH FL
32114
US

IV. Provider business mailing address

421 SOUTH KEECH ST
DAYTONA BEACH FL
32114
US

V. Phone/Fax

Practice location:
  • Phone: 386-238-4980
  • Fax: 386-254-3937
Mailing address:
  • Phone: 386-238-4980
  • Fax: 386-254-3937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateFL

VIII. Authorized Official

Name: MS. CATHY KEATHLEY
Title or Position: PROGRAM ADMINISTRATOR
Credential:
Phone: 352-334-1394