Healthcare Provider Details

I. General information

NPI: 1447600747
Provider Name (Legal Business Name): EDWARDS-EBANKS RESIDENTIAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 05/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 43RD ST
WEST PALM BEACH FL
33407-3851
US

IV. Provider business mailing address

2264 SW MANELE PL
PALM CITY FL
34990-8817
US

V. Phone/Fax

Practice location:
  • Phone: 561-459-0578
  • Fax:
Mailing address:
  • Phone: 561-459-0578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name: LORNA EBANKS
Title or Position: MGR
Credential:
Phone: 561-459-0578