MEDICARE: MR. CHARLES HOWARD DEAN CBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency	251COOOOOX	FL

General Provider Information

NPI Number	:	1093835910
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES HOWARD DEAN CBA

Provider Business Mailing Address
First Line	:	1024 40TH AVE NE
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33703-5228
Country	:	US
Telephone Number	:	727-821-6932
Fax Number	:

Provider Business Practice Location Address
First Line	:	1024 40TH AVE NE
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33703-5228
Country	:	US
Telephone Number	:	727-821-6932
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	07/09/2007

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