Healthcare Provider Details

I. General information

NPI: 1912308990
Provider Name (Legal Business Name): OWNER BUILDER ASSISTANCE CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2014
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2357 SW ANTIQUERA ST
PORT ST LUCIE FL
34953-2436
US

IV. Provider business mailing address

2357 SW ANTIQUERA ST
PORT ST LUCIE FL
34953-2436
US

V. Phone/Fax

Practice location:
  • Phone: 561-339-9575
  • Fax:
Mailing address:
  • Phone: 561-339-9575
  • Fax: 772-236-9596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License NumberCGC038404
License Number StateFL

VIII. Authorized Official

Name: MR. DONALD LEE MALONE
Title or Position: PRESIDENT
Credential:
Phone: 561-339-9575