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General NPI Number Information
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NPI Number | 1124443346
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Entity Type | Organization
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Legal Business Name | LIBRA 85
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Dates
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Enumeration Date | 02/25/2014
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Last Update Date | 02/25/2014
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Provider Practice Location Address
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Address Line | 624 S ATLANTIC AVE
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City | DAYTONA BEACH
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State | FL
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Zip | 32118-4510
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Country | US
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Telephone | 386-315-0899
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Fax |
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Provider Business Mailing Address
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Address Line | 624 S ATLANTIC AVE
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City | DAYTONA BEACH
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State | FL
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Zip | 32118-4510
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JACEK DYGDON
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Credential |
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Telephone | 386-315-0899
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number | AL5675
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License Number State | FL
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