=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427385632
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIGGS MIRACLE CARE OF VOLUSIA AND FLAGLER COUNTIES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2009
-----------------------------------------------------
Last Update Date | 11/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 875 DR MARY MCLEOD BETHUNE BLVD SUITE B
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-3602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-323-9067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 875 DR MARY MCLEOD BETHUNE BLVD SUITE B
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-3602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-323-9067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM MANAGER
-----------------------------------------------------
Name | MS. TERESA M BROXTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-323-9855
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251V00000X
-----------------------------------------------------
Taxonomy Name | Voluntary or Charitable Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------