Healthcare Provider Details

I. General information

NPI: 1447259254
Provider Name (Legal Business Name): PROGRESSIVE HEALTH CARE PROVIDERS/FERN PARK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 FERN PARK BLVD
FERN PARK FL
32730-2500
US

IV. Provider business mailing address

230 FERN PARK BLVD
FERN PARK FL
32730-2500
US

V. Phone/Fax

Practice location:
  • Phone: 407-331-7231
  • Fax: 407-331-9251
Mailing address:
  • Phone: 407-331-7231
  • Fax: 407-331-9251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number4022095
License Number StateFL

VIII. Authorized Official

Name: MR. TERRY REVELL
Title or Position: ADMINISTRATOR
Credential:
Phone: 407-331-7231