=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205178258
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATRICIA'S ROCK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2013
-----------------------------------------------------
Last Update Date | 03/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 750 S ORANGE BLOSSOM TRL
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32805-3118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-758-4910
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4325 FOUNTAINVIEW LN #5102
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32808-1198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-566-1975
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | D/P
-----------------------------------------------------
Name | DE LISA BONAPARTE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-566-1975
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251V00000X
-----------------------------------------------------
Taxonomy Name | Voluntary or Charitable Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------