Healthcare Provider Details

I. General information

NPI: 1306142864
Provider Name (Legal Business Name): ICI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9462 SW 31ST LN
GAINESVILLE FL
32608-7921
US

IV. Provider business mailing address

9462 SW 31ST LN
GAINESVILLE FL
32608-7921
US

V. Phone/Fax

Practice location:
  • Phone: 352-222-8968
  • Fax:
Mailing address:
  • Phone: 352-222-8968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: SVETLANA KOROTKEVICH
Title or Position: REG AGENT
Credential:
Phone: 352-222-8968