Healthcare Provider Details

I. General information

NPI: 1497301303
Provider Name (Legal Business Name): M&A DISABLE VETERANS ASSISTANT LIVING HOME & MINISTRY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 SW MACKENZIE ST
PORT SAINT LUCIE FL
34953-1329
US

IV. Provider business mailing address

1850 SW MACKENZIE ST
PORT SAINT LUCIE FL
34953-1329
US

V. Phone/Fax

Practice location:
  • Phone: 772-200-0436
  • Fax: 866-270-2817
Mailing address:
  • Phone: 772-200-0436
  • Fax: 866-270-2817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK ANTHONY ANDERSON
Title or Position: OWNER /DIRECTOR
Credential: CLERGY, CHAPLAIN
Phone: 772-200-0436