Healthcare Provider Details

I. General information

NPI: 1336478304
Provider Name (Legal Business Name): SEQUEL TSI OF FLORIDA, LLC MARION PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2009
Last Update Date: 12/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10420 NW GAINESVILLE RD
OCALA FL
34482-1446
US

IV. Provider business mailing address

10420 NW GAINESVILLE RD
OCALA FL
34482-1446
US

V. Phone/Fax

Practice location:
  • Phone: 352-840-8240
  • Fax: 352-840-8256
Mailing address:
  • Phone: 352-840-8240
  • Fax: 352-840-8256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number0542AD9709
License Number StateFL

VIII. Authorized Official

Name: MR. JOHN STUPAK
Title or Position: PRESIDENT
Credential:
Phone: 267-419-8913