Healthcare Provider Details

I. General information

NPI: 1083532253
Provider Name (Legal Business Name): CHIPOLA RESIDENTIAL REHABILITATIVE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2419 FAIRVIEW RD
MARIANNA FL
32448-2629
US

IV. Provider business mailing address

2419 FAIRVIEW RD
MARIANNA FL
32448-2629
US

V. Phone/Fax

Practice location:
  • Phone: 850-526-0027
  • Fax:
Mailing address:
  • Phone: 850-526-0027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: EMILY TILLMAN
Title or Position: MANAGER
Credential: MANAGER
Phone: 850-354-0017