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General NPI Number Information
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NPI Number | 1447359435
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Entity Type | Organization
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Legal Business Name | BRISTOL YOUTH ACADEMY
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Dates
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Enumeration Date | 09/22/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 12422 NW GORDON TRUETT REVELL RD
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City | BRISTOL
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State | FL
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Zip | 32321-3007
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Country | US
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Telephone | 850-643-4600
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Fax | 850-643-2061
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Provider Business Mailing Address
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Address Line | 12422 NW GORDON TRUETT REVELL RD
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City | BRISTOL
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State | FL
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Zip | 32321-3007
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Country | US
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Telephone | 850-643-4600
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Fax | 850-643-2061
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Authorized Official
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Title or Position | ADMIN
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Name | JEANETTE JACKSON
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Credential |
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Telephone | 850-643-4600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number |
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License Number State |
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