Provider Demographics
NPI:1154382489
Name:BREATH OF LIFE OF CENTRAL FL.
Entity type:Organization
Organization Name:BREATH OF LIFE OF CENTRAL FL.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ACQUANETTA
Authorized Official - Middle Name:G
Authorized Official - Last Name:MOORE-ELERBE
Authorized Official - Suffix:
Authorized Official - Credentials:CDVC II, DD
Authorized Official - Phone:352-255-8061
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:LAKE PANASOFFKEE
Mailing Address - State:FL
Mailing Address - Zip Code:33538-0220
Mailing Address - Country:US
Mailing Address - Phone:352-255-8061
Mailing Address - Fax:352-418-3148
Practice Address - Street 1:838 W DESOTO ST STE E
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2110
Practice Address - Country:US
Practice Address - Phone:352-255-8061
Practice Address - Fax:352-418-3148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2010-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25093174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty