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General NPI Number Information
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NPI Number | 1942600580
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Entity Type | Organization
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Legal Business Name | FDLRS/GATEWAY
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Dates
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Enumeration Date | 09/02/2014
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Last Update Date | 09/02/2014
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Provider Practice Location Address
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Address Line | 5683 US HIGHWAY 129 S
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City | JASPER
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State | FL
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Zip | 32052-6793
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Country | US
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Telephone | 386-792-2877
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Fax |
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Provider Business Mailing Address
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Address Line | 5683 US HIGHWAY 129 S
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City | JASPER
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State | FL
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Zip | 32052-6793
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Country | US
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Telephone | 386-792-2877
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Fax |
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Authorized Official
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Title or Position | PROJECT COORDINATOR
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Name | CAROL MILTON
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Credential |
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Telephone | 386-792-2877
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | 9188843
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License Number State | FL
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