Healthcare Provider Details

I. General information

NPI: 1649445842
Provider Name (Legal Business Name): MENTORING & MOTIVATING YOUTH OF AMERICA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 FRIENDSHIP DR
ORLANDO FL
32835-4407
US

IV. Provider business mailing address

475 FRIENDSHIP DR
ORLANDO FL
32835-4407
US

V. Phone/Fax

Practice location:
  • Phone: 407-578-2993
  • Fax: 407-578-4588
Mailing address:
  • Phone: 407-578-2993
  • Fax: 407-578-4588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number50001043735
License Number StateFL

VIII. Authorized Official

Name: MR. STAN B. MORRIS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 407-578-2993