=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114407574
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOOD SAMARITAN VILLAGE LLLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2018
-----------------------------------------------------
Last Update Date | 08/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26442 WHIRLAWAY TER
-----------------------------------------------------
City | WESLEY CHAPEL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33544-1552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-794-6457
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26442 WHIRLAWAY TER
-----------------------------------------------------
City | WESLEY CHAPEL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33544-1552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-558-4189
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DERRICK APPIAH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-558-4189
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD1600X
-----------------------------------------------------
Taxonomy Name | Developmental Disabilities Clinic/Center
-----------------------------------------------------
License Number | 714547
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------