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General NPI Number Information
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NPI Number | 1558618454
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Entity Type | Organization
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Legal Business Name | BRAIN DISORDER SUPPORT FOUNDATION, INC.
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Dates
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Enumeration Date | 08/09/2012
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Last Update Date | 08/09/2012
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Provider Practice Location Address
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Address Line | 353 JUNIPER LAKE RD
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City | DEFUNIAK SPRINGS
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State | FL
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Zip | 32433-3514
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Country | US
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Telephone | 850-892-0565
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Fax | 850-520-4651
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Provider Business Mailing Address
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Address Line | 353 JUNIPER LAKE RD
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City | DEFUNIAK SPRINGS
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State | FL
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Zip | 32433-3514
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Country | US
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Telephone | 850-892-0565
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Fax | 850-520-4651
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Authorized Official
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Title or Position | ADMINISTRATOT
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Name | MRS. HILDA R COURSEY
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Credential |
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Telephone | 850-892-0565
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number | AHCA #9115
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License Number State | FL
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