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General NPI Number Information
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NPI Number | 1346407111
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Entity Type | Organization
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Legal Business Name | WINGS OF LOVE OF LEESBURG, LLC
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Dates
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Enumeration Date | 05/20/2008
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Last Update Date | 05/20/2008
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Provider Practice Location Address
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Address Line | 1018 W NORTH BLVD
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City | LEESBURG
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State | FL
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Zip | 34748-5057
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Country | US
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Telephone | 352-360-0660
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Fax | 352-360-0567
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Provider Business Mailing Address
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Address Line | PO BOX 491077
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City | LEESBURG
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State | FL
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Zip | 34749-1077
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Country | US
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Telephone | 352-360-0660
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Fax | 352-360-0567
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. PERNELL MITCHELL
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Credential |
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Telephone | 352-360-0660
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number | 688587096
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License Number State | FL
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