Healthcare Provider Details

I. General information

NPI: 1780099523
Provider Name (Legal Business Name): EASTERSEALS NORTHEAST CENTRAL FLORIDA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2014
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: 386-258-7677
Mailing address:
  • Phone: 386-255-4568
  • Fax: 386-258-7677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. BEVERLY JOHNSON
Title or Position: PRESIDENT
Credential:
Phone: 386-944-7818