Healthcare Provider Details

I. General information

NPI: 1528417391
Provider Name (Legal Business Name): FLORRY CREATIVE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2016
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 HOLLOMAN RD
PLANT CITY FL
33567-3706
US

IV. Provider business mailing address

PO BOX 5636
PLANT CITY FL
33563-0047
US

V. Phone/Fax

Practice location:
  • Phone: 813-650-8242
  • Fax: 866-240-5666
Mailing address:
  • Phone: 813-650-8242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberAL12847
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberAL12847
License Number StateFL

VIII. Authorized Official

Name: CHERRY HALLBACK
Title or Position: ADMINISTRATOR
Credential:
Phone: 813-650-8242