Healthcare Provider Details

I. General information

NPI: 1992309660
Provider Name (Legal Business Name): GREAT EXPECTATIONS KID'S HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2020
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11216 108TH WAY
LARGO FL
33778-3320
US

IV. Provider business mailing address

13494 WALSINGHAM RD
LARGO FL
33774-3527
US

V. Phone/Fax

Practice location:
  • Phone: 727-488-1493
  • Fax:
Mailing address:
  • Phone: 727-735-1317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. GEORGE F ENSOR
Title or Position: ADMINITRATOR
Credential:
Phone: 727-735-1317