Healthcare Provider Details

I. General information

NPI: 1699806190
Provider Name (Legal Business Name): DAKOTA SHEBA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 02/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 N ORLANDO AVE SUITE 280
WINTER PARK FL
32789-3606
US

IV. Provider business mailing address

140 N ORLANDO AVE SUITE 280
WINTER PARK FL
32789-3606
US

V. Phone/Fax

Practice location:
  • Phone: 407-644-7396
  • Fax:
Mailing address:
  • Phone: 407-644-7396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number229143
License Number StateFL

VIII. Authorized Official

Name: MR. JOHN C KIRCHNER
Title or Position: OWNER
Credential:
Phone: 407-644-7396