Healthcare Provider Details

I. General information

NPI: 1053764985
Provider Name (Legal Business Name): HOPE CENTERS OF CENTRAL FLORIDA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E MILLER ST
ORLANDO FL
32806-2123
US

IV. Provider business mailing address

1507 S HIAWASSEE RD SUITE 107
ORLANDO FL
32835-5718
US

V. Phone/Fax

Practice location:
  • Phone: 407-246-6620
  • Fax: 407-299-9141
Mailing address:
  • Phone: 407-445-9545
  • Fax: 407-299-9141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: STACEY WADE
Title or Position: ADMINISTRATOR
Credential:
Phone: 407-445-9545