Healthcare Provider Details

I. General information

NPI: 1558545475
Provider Name (Legal Business Name): BISHOP GRADY VILLAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 03/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BISHOP GRADY CT
SAINT CLOUD FL
34769-1538
US

IV. Provider business mailing address

401 BISHOP GRADY CT
SAINT CLOUD FL
34769-1538
US

V. Phone/Fax

Practice location:
  • Phone: 407-892-6078
  • Fax: 407-892-8081
Mailing address:
  • Phone: 407-892-6078
  • Fax: 407-892-8081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL10398
License Number StateFL

VIII. Authorized Official

Name: MR. KEVIN CHARLES JOHNSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 407-892-6078