Healthcare Provider Details

I. General information

NPI: 1609316272
Provider Name (Legal Business Name): DELMAR GLEN PACK PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2017
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 BRIARWOOD CT
ORANGE CITY FL
32763-4319
US

IV. Provider business mailing address

810 BRIARWOOD CT
ORANGE CITY FL
32763-4319
US

V. Phone/Fax

Practice location:
  • Phone: 386-956-1689
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY6914
License Number StateFL

VIII. Authorized Official

Name: CORINNE ZIMMERMAN
Title or Position: ENROLLMENT SPECIALIST
Credential:
Phone: 954-366-2700