Healthcare Provider Details

I. General information

NPI: 1093875650
Provider Name (Legal Business Name): AGENCY FOR PERSONS WITH DISABILITIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 WILLIAMS DRIVE
MARIANNA FL
32446
US

IV. Provider business mailing address

3700 WILLIAMS DRIVE
MARIANNA FL
32446
US

V. Phone/Fax

Practice location:
  • Phone: 850-482-9220
  • Fax: 850-718-0434
Mailing address:
  • Phone: 850-482-9220
  • Fax: 850-718-0434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. JEFFREY DAVID EGELSTON
Title or Position: SUPERINTENDENT
Credential: ED.D.
Phone: 850-482-9210