Healthcare Provider Details

I. General information

NPI: 1336203702
Provider Name (Legal Business Name): EASTERSEALS NORTHEAST CENTRAL FLORIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 DUNN AVE
DAYTONA BEACH FL
32114
US

IV. Provider business mailing address

1219 DUNN AVE
DAYTONA BEACH FL
32114-2405
US

V. Phone/Fax

Practice location:
  • Phone: 386-255-4568
  • Fax:
Mailing address:
  • Phone: 386-255-4568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License NumberOT 424
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License NumberOT424
License Number StateFL

VIII. Authorized Official

Name: BEVERLY JOHNSON
Title or Position: DIRECTOR
Credential:
Phone: 386-255-4568