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General NPI Number Information
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NPI Number | 1861732851
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Entity Type | Organization
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Legal Business Name | MORNING GLORY HOUSE OF LOVE
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Dates
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Enumeration Date | 02/27/2013
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Last Update Date | 02/27/2013
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Provider Practice Location Address
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Address Line | 120 MAPLE AVE SAME
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City | FORT PIERCE
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State | FL
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Zip | 34982-3431
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Country | US
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Telephone | 772-672-1181
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Fax | 772-489-7825
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Provider Business Mailing Address
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Address Line | 120 MAPLE AVE SAME
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City | FORT PIERCE
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State | FL
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Zip | 34982-3431
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Country | US
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Telephone | 772-672-1181
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Fax | 772-489-7825
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Authorized Official
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Title or Position | DIRECTORR/OWNER
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Name | MRS. MYRTLE MARINA PETERSON
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Credential | MASTERS
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Telephone | 772-672-1181
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 6905990
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License Number State | FL
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