Healthcare Provider Details

I. General information

NPI: 1255658365
Provider Name (Legal Business Name): 98
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 04/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11314 MAHOPAC RD
WEEKI WACHEE FL
34614-3562
US

IV. Provider business mailing address

11314 MAHOPAC RD
WEEKI WACHEE FL
34614-3562
US

V. Phone/Fax

Practice location:
  • Phone: 813-410-7719
  • Fax:
Mailing address:
  • Phone: 813-410-7719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberCNA27905
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License NumberCNA27905
License Number StateFL

VIII. Authorized Official

Name: MILO DFERIVAL
Title or Position: CNA
Credential: CNA
Phone: 813-410-7719