Healthcare Provider Details

I. General information

NPI: 1558446963
Provider Name (Legal Business Name): CENTRAL FLORIDA CHILD HEALTH PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7040 LAKE ELLENOR DRIVE
ORLANDO FL
32809-5750
US

IV. Provider business mailing address

7040 LAKE ELLENOR DRIVE
ORLANDO FL
32809-5750
US

V. Phone/Fax

Practice location:
  • Phone: 407-858-6143
  • Fax: 407-856-6594
Mailing address:
  • Phone: 407-858-6143
  • Fax: 407-856-6594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. CATHLEEN O. MARK
Title or Position: PROJECT ADMINISTRATOR
Credential:
Phone: 407-858-6143