Healthcare Provider Details

I. General information

NPI: 1790695062
Provider Name (Legal Business Name): HOLDEN RIDGE COMMUNITY LIVING S CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1244 TYLER LAKE CIR
ORLANDO FL
32839-1995
US

IV. Provider business mailing address

1244 TYLER LAKE CIR
ORLANDO FL
32839-1995
US

V. Phone/Fax

Practice location:
  • Phone: 954-552-4366
  • Fax: 877-518-7525
Mailing address:
  • Phone: 954-552-4366
  • Fax: 877-518-7525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. TESFAMARIAM G BAHTA
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 954-552-4366