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General NPI Number Information
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NPI Number | 1346676848
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Entity Type | Organization
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Legal Business Name | GWENANDREWS HOME OF SUCCESS AGENCY, INC.
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Dates
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Enumeration Date | 09/17/2013
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Last Update Date | 09/17/2013
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Provider Practice Location Address
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Address Line | 116 N MADISON ST
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City | QUINCY
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State | FL
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Zip | 32351-2411
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Country | US
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Telephone | 850-875-0075
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Fax | 850-627-2614
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Provider Business Mailing Address
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Address Line | 116 N MADISON ST
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City | QUINCY
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State | FL
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Zip | 32351-2411
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Country | US
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Telephone | 850-875-0075
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Fax | 850-627-2614
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. EREKA ANDREWS REDDICK
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Credential |
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Telephone | 850-875-0075
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 385HR2060X
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Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
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License Number | 691333496
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License Number State | FL
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