=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447809041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VALDEVIN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2019
-----------------------------------------------------
Last Update Date | 09/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2746 BIG PINE DR
-----------------------------------------------------
City | HOLIDAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34691-8763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-495-8345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4020
-----------------------------------------------------
City | HOLIDAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34692-1020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-495-8345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING DIRECTOR
-----------------------------------------------------
Name | MR. EBENEZER BALOGUN FAULKNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-495-8345
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD1600X
-----------------------------------------------------
Taxonomy Name | Developmental Disabilities Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------