Healthcare Provider Details

I. General information

NPI: 1962250233
Provider Name (Legal Business Name): SUPPORTING INDIVIDUALS WITH DISABILITIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2024
Last Update Date: 05/10/2024
Certification Date: 05/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95129 SPRINGHILL RD
FERNANDINA BEACH FL
32034-9410
US

IV. Provider business mailing address

95129 SPRINGHILL RD
FERNANDINA BEACH FL
32034-9410
US

V. Phone/Fax

Practice location:
  • Phone: 904-507-9976
  • Fax:
Mailing address:
  • Phone: 904-507-9976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: JESSICA D FREEMAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 904-507-9976