=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467879130
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HALLEY ACOSTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2014
-----------------------------------------------------
Last Update Date | 03/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 259 BILL FRANCE BLVD SUITE 200
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-1316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-444-1390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2130 N NORMANDY BLVD
-----------------------------------------------------
City | DELTONA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32725-2612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-444-1390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------