=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285711960
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOYS TOWN NORTH FLORIDA, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 03/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3555 COMMONWEALTH BLVD
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32303-3119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-575-6422
-----------------------------------------------------
Fax | 850-575-7158
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3555 COMMONWEALTH BLVD
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32303-3119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-575-6422
-----------------------------------------------------
Fax | 850-575-7158
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. MARCUS LAMPKIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-504-5017
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | 0700-01-06
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------