=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407468986
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WINCHESTER OAKS CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2020
-----------------------------------------------------
Last Update Date | 08/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 871 WINCHESTER ST
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-1977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-795-0353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 871 WINCHESTER ST
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-1977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-795-0353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CICELY JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-759-0353
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------