=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912077017
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DISC VILLAGE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2006
-----------------------------------------------------
Last Update Date | 02/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 85 HIGH DR
-----------------------------------------------------
City | CRAWFORDVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32327-2032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-926-2452
-----------------------------------------------------
Fax | 850-926-8355
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3333 W PENSACOLA ST
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32304-2888
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-575-4388
-----------------------------------------------------
Fax | 850-576-3317
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | QA DIRECTOR
-----------------------------------------------------
Name | MELISSA SKIPTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-766-1251
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------