=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952721177
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUBSTANCE ABUSE TREATMENT OF SEMINOLE COUNTY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2014
-----------------------------------------------------
Last Update Date | 04/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2640 HIAWATHA AVE SUITE E
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32773-5342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-330-7373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2640 HIAWATHA AVE SUITE E
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32773-5342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-330-7373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/ CLINICAL DIRECTOR
-----------------------------------------------------
Name | MR. TYRONE TYUS
-----------------------------------------------------
Credential | REV.
-----------------------------------------------------
Telephone | 386-738-1473
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | DCF 1859AD523601
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------