MEDICARE: AMERICAN CENTER FOR INTELLECTUAL AND DIVERSE DISORDERS FLORIDA, INC

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1881136505
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMERICAN CENTER FOR INTELLECTUAL AND DIVERSE DISORDERS FLORIDA, INC

Provider Business Mailing Address
First Line	:	20617 WHITEWOOD WAY
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-3216
Country	:	US
Telephone Number	:	862-221-8282
Fax Number	:

Provider Business Practice Location Address
First Line	:	20617 WHITEWOOD WAY
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-3216
Country	:	US
Telephone Number	:	862-221-8282
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MR. ABY OOMMEN
Credential	:
Telephone Number	:	862-221-8282

Provider Enumeration Date	:	11/11/2016
Last Update Date	:	11/11/2016

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