MEDICARE: PARKVIEW OUTREACH COMMUNITY CENTER

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	251V00000X	Voluntary or Charitable Agency

General Provider Information

NPI Number	:	1487968806
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARKVIEW OUTREACH COMMUNITY CENTER

Provider Business Mailing Address
First Line	:	1205 DR MARTIN L KING JR WAY
Second Line	:
City	:	HAINES CITY
State	:	FL
Zip	:	33844-3490
Country	:	US
Telephone Number	:	863-353-6853
Fax Number	:	863-438-2752

Provider Business Practice Location Address
First Line	:	1205 DR MARTIN L KING JR WAY
Second Line	:
City	:	HAINES CITY
State	:	FL
Zip	:	33844-3490
Country	:	US
Telephone Number	:	863-353-6853
Fax Number	:	863-438-2752

Authorized Official
Title or Position	:	CHAIRMAN OF THE BOARD
Name	:	ROOSEVELT THOMAS JR.
Credential	:	ED.D.
Telephone Number	:	863-353-6853

Provider Enumeration Date	:	07/27/2010
Last Update Date	:	07/27/2010

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