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General NPI Number Information
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NPI Number | 1356764823
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Entity Type | Organization
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Legal Business Name | EXTENDED FAMILY ALR INC
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Dates
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Enumeration Date | 02/03/2014
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Last Update Date | 02/03/2014
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Provider Practice Location Address
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Address Line | 1020 CLAUDIA ST
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City | NEW SMYRNA BEACH
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State | FL
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Zip | 32168-6354
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Country | US
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Telephone | 386-957-3907
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Fax | 386-957-6316
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Provider Business Mailing Address
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Address Line | 2505 W LAKE DR
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City | DELAND
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State | FL
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Zip | 32724-3245
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Country | US
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Telephone | 386-957-3907
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Fax | 386-957-6316
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. MATTHEW HAWKINS SR.
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Credential |
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Telephone | 386-957-3907
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320700000X
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Taxonomy Name | Physical Disabilities Residential Treatment Facility
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License Number | AL12247
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License Number State | FL
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