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General NPI Number Information
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NPI Number | 1447259254
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Entity Type | Organization
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Legal Business Name | PROGRESSIVE HEALTH CARE PROVIDERS/FERN PARK, LLC
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Dates
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Enumeration Date | 07/14/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 230 FERN PARK BLVD
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City | FERN PARK
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State | FL
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Zip | 32730-2500
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Country | US
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Telephone | 407-331-7231
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Fax | 407-331-9251
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Provider Business Mailing Address
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Address Line | 230 FERN PARK BLVD
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City | FERN PARK
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State | FL
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Zip | 32730-2500
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Country | US
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Telephone | 407-331-7231
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Fax | 407-331-9251
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. TERRY REVELL
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Credential |
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Telephone | 407-331-7231
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 4022095
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License Number State | FL
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