=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508225053
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCCALL SERVICE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2016
-----------------------------------------------------
Last Update Date | 02/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 415 NW 250TH ST SUITE 1
-----------------------------------------------------
City | NEWBERRY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32669-4473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-342-6948
-----------------------------------------------------
Fax | 866-961-4919
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 NW 250TH ST SUITE 1
-----------------------------------------------------
City | NEWBERRY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32669-4473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-342-6948
-----------------------------------------------------
Fax | 866-961-4919
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | BRYAN J COOKSEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 800-342-6948
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311Z00000X
-----------------------------------------------------
Taxonomy Name | Custodial Care Facility
-----------------------------------------------------
License Number | JB144629
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------