Healthcare Provider Details

I. General information

NPI: 1184925752
Provider Name (Legal Business Name): JOHN BIRD COMMUNITY SUPPORTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2010
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4788 253RD ST E
MYAKKA CITY FL
34251-8956
US

IV. Provider business mailing address

4788 253RD ST E
MYAKKA CITY FL
34251-8956
US

V. Phone/Fax

Practice location:
  • Phone: 941-920-1533
  • Fax: 941-362-9798
Mailing address:
  • Phone: 941-920-1533
  • Fax: 941-362-9798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number000992301
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number000992300
License Number StateFL

VIII. Authorized Official

Name: MS. LINDA IERENE FLORES
Title or Position: VICE PRESIDENT
Credential:
Phone: 941-685-9684