=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629479241
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTH ENRICHMENT LIFESKILLE PROGRAM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2014
-----------------------------------------------------
Last Update Date | 09/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2332 N HIAWASSEE RD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32818-3961
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-298-7080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2332 N HIAWASSEE RD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32818-3961
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-298-7080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | DR. INGRID R BISHOP
-----------------------------------------------------
Credential | EDD
-----------------------------------------------------
Telephone | 407-694-6100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------