Healthcare Provider Details

I. General information

NPI: 1326183377
Provider Name (Legal Business Name): EASTERSEALS NORTHEAST CENTRAL FLORIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 W NEW YORK AVE
DELAND FL
32720-5239
US

IV. Provider business mailing address

1219 DUNN AVE P.O. BOX 9117
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 TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number34167
License Number StateFL

VIII. Authorized Official

Name: MRS. BEVERLY JOHNSON
Title or Position: CEO
Credential:
Phone: 386-255-4568