Healthcare Provider Details

I. General information

NPI: 1356764823
Provider Name (Legal Business Name): EXTENDED FAMILY ALR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2014
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 CLAUDIA ST
NEW SMYRNA BEACH FL
32168-6354
US

IV. Provider business mailing address

2505 W LAKE DR
DELAND FL
32724-3245
US

V. Phone/Fax

Practice location:
  • Phone: 386-957-3907
  • Fax: 386-957-6316
Mailing address:
  • Phone: 386-957-3907
  • Fax: 386-957-6316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License NumberAL12247
License Number StateFL

VIII. Authorized Official

Name: MR. MATTHEW HAWKINS SR.
Title or Position: PRESIDENT
Credential:
Phone: 386-957-3907