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General NPI Number Information
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NPI Number | 1558667279
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Entity Type | Organization
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Legal Business Name | SOUTHERN PARKS INC
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Dates
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Enumeration Date | 01/27/2011
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Last Update Date | 02/16/2011
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Provider Practice Location Address
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Address Line | 157 WILL DUKES RD
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City | WAUCHULA
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State | FL
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Zip | 33873-9308
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Country | US
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Telephone | 863-773-9557
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Fax | 863-773-0764
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Provider Business Mailing Address
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Address Line | 157 WILL DUKES RD
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City | WAUCHULA
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State | FL
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Zip | 33873-9308
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Country | US
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Telephone | 863-773-9557
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Fax | 863-773-0764
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. SANNY PRADO PANINGBATAN
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Credential |
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Telephone | 863-773-9557
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number | AL7853
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License Number State | FL
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