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General NPI Number Information
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NPI Number | 1912193673
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Entity Type | Organization
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Legal Business Name | MANDIC GROUP INC
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Dates
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Enumeration Date | 09/17/2007
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Last Update Date | 09/17/2007
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Provider Practice Location Address
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Address Line | 5155 US HIGHWAY 1 S
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-7855
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Country | US
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Telephone | 904-797-5027
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Fax | 904-797-5577
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Provider Business Mailing Address
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Address Line | 5155 US HIGHWAY 1 S
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-7855
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Country | US
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Telephone | 904-797-5027
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Fax | 904-797-5577
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Authorized Official
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Title or Position | OWNER/PRES.
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Name | MR. MARK MANDIC
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Credential |
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Telephone | 904-797-5027
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 4075096
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License Number State | FL
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