=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548362684
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE ARC OF INDIAN RIVER COUNTY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2006
-----------------------------------------------------
Last Update Date | 08/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1375 16TH AVE
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-562-6854
-----------------------------------------------------
Fax | 772-562-6063
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1375 16TH AVE
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-562-6854
-----------------------------------------------------
Fax | 772-562-6063
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. CHARLES A. BRADLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-562-6854
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | F491626205004
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | F491626205004
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | F491626205004
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number | F491626205004
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------