Healthcare Provider Details

I. General information

NPI: 1518172493
Provider Name (Legal Business Name): MVP SUPPORT SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2007
Last Update Date: 01/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 SAN JOSE RD
ST AUGUSTINE FL
32086-6551
US

IV. Provider business mailing address

701 SAN JOSE RD
ST AUGUSTINE FL
32086-6551
US

V. Phone/Fax

Practice location:
  • Phone: 904-669-8446
  • Fax:
Mailing address:
  • Phone: 904-669-8446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number229996
License Number StateFL

VIII. Authorized Official

Name: CATHERINE M CASON
Title or Position: OWNER
Credential:
Phone: 904-669-8446