=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528417391
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORRY CREATIVE CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2016
-----------------------------------------------------
Last Update Date | 01/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1404 HOLLOMAN RD
-----------------------------------------------------
City | PLANT CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33567-3706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-650-8242
-----------------------------------------------------
Fax | 866-240-5666
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5636
-----------------------------------------------------
City | PLANT CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33563-0047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-650-8242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | CHERRY HALLBACK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-650-8242
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | AL12847
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number | AL12847
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------