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General NPI Number Information
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NPI Number | 1467805465
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Entity Type | Organization
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Legal Business Name | OCEAN ROAD LLC
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Dates
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Enumeration Date | 07/14/2016
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Last Update Date | 07/14/2016
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Provider Practice Location Address
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Address Line | 3520 W INTERNATIONAL SPEEDWAY BLVD
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City | DAYTONA BEACH
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State | FL
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Zip | 32124-1026
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Country | US
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Telephone | 386-527-2160
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2633
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City | BUNNELL
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State | FL
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Zip | 32110-2633
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Country | US
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Telephone | 386-527-2160
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. ELIZABETH ANN FERGUSON
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Credential | L.C.S.W.
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Telephone | 386-527-2160
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | SW10893
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License Number State | FL
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