Healthcare Provider Details

I. General information

NPI: 1295195527
Provider Name (Legal Business Name): ZION LW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2016
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 PUTTER PL
KISSIMMEE FL
34746-3971
US

IV. Provider business mailing address

2109 PUTTER PL
KISSIMMEE FL
34746-3971
US

V. Phone/Fax

Practice location:
  • Phone: 407-435-4791
  • Fax:
Mailing address:
  • Phone: 407-435-4791
  • Fax: 407-264-8357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: LIDICE VALENCIA
Title or Position: CEO
Credential: CBHCMS, BA, BS
Phone: 407-435-4791