MEDICARE: SUPPORT INDEPENDENT LIVING

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	261QD1600X	Developmental Disabilities Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306590260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPPORT INDEPENDENT LIVING

Provider Business Mailing Address
First Line	:	11 RACETRACK RD NE STE C2
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1867
Country	:	US
Telephone Number	:	850-259-7190
Fax Number	:	850-862-4849

Provider Business Practice Location Address
First Line	:	11 RACETRACK RD NE STE C2
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1867
Country	:	US
Telephone Number	:	850-259-7190
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRENDA F MARRIER
Credential	:
Telephone Number	:	850-259-7190

Provider Enumeration Date	:	02/09/2022
Last Update Date	:	02/09/2022

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Directions to “SUPPORT INDEPENDENT LIVING ” Practice Location

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