Healthcare Provider Details

I. General information

NPI: 1679734396
Provider Name (Legal Business Name): NETTIE MAE BERRY FOUNDATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 NE 39TH PL
GAINESVILLE FL
32609-1717
US

IV. Provider business mailing address

113 NE 39TH PL
GAINESVILLE FL
32609-1717
US

V. Phone/Fax

Practice location:
  • Phone: 352-258-3450
  • Fax: 352-376-5474
Mailing address:
  • Phone: 352-258-3450
  • Fax: 352-376-5474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number689678298
License Number StateFL

VIII. Authorized Official

Name: MS. TANDRA LAIMIKIA SIMMONS
Title or Position: OWNER
Credential:
Phone: 352-258-3450