=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265196661
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PANSY'S PLACE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2021
-----------------------------------------------------
Last Update Date | 10/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2058 PINEHURST DR
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33407-3546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-287-0305
-----------------------------------------------------
Fax | 561-247-7627
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1905 W BLUE HERON BLVD
-----------------------------------------------------
City | RIVIERA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33404-5149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-287-0305
-----------------------------------------------------
Fax | 567-247-7627
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | MS. SHEMIA TIERRE PRINCE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-287-0308
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------