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General NPI Number Information
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NPI Number | 1245417732
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Entity Type | Organization
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Legal Business Name | WESLEY HOUSE AIF
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Dates
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Enumeration Date | 01/28/2008
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Last Update Date | 01/28/2008
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Provider Practice Location Address
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Address Line | 1500 MARIMILLIAN DR
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City | WESLEY CHAPEL
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State | FL
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Zip | 33543
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Country | US
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Telephone | 813-770-1605
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Fax |
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Provider Business Mailing Address
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Address Line | 1500 MARIMILLIAN DR
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City | WESLEY CHAPEL
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State | FL
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Zip | 33543
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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 | ADMINISTRATOR
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Name | MRS. LOLA I JEGREDE
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Credential |
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Telephone | 813-469-4496
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number | AL9256
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | AL9256
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 347C00000X
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Taxonomy Name | Private Vehicle
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License Number | AL9256
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License Number State | FL
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