=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124168570
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTER SEALS OF VOLUSIA AND FLAGLER COUNTIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1219 DUNN AVE
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-2405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-255-4568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1219 DUNN AVE
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-2405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | LYNN SINNOTT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-255-2468
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | OT10387
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------