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General NPI Number Information
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NPI Number | 1730316688
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Entity Type | Organization
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Legal Business Name | COUNTRY ACRES GROUP HOME
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Dates
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Enumeration Date | 06/18/2009
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Last Update Date | 06/18/2009
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Provider Practice Location Address
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Address Line | 1850 S DELEON AVE
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City | TITUSVILLE
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State | FL
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Zip | 32780-7733
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Country | US
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Telephone | 321-264-5000
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Fax | 321-264-5195
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Provider Business Mailing Address
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Address Line | 1850 S DELEON AVE
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City | TITUSVILLE
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State | FL
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Zip | 32780-7733
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Country | US
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Telephone | 321-264-5000
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Fax | 321-264-5195
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Authorized Official
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Title or Position | DIRECTOR HOUSING HUMAN SERVICES
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Name | MRS. GAY WILLIAMS
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Credential |
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Telephone | 321-264-5000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253J00000X
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Taxonomy Name | Foster Care Agency
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License Number | 18-1073-025-08
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License Number State | FL
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