Provider Demographics
NPI:1194314245
Name:HALCYON PLACE LLC
Entity type:Organization
Organization Name:HALCYON PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-210-4098
Mailing Address - Street 1:3501 BESSIE COLEMAN BLVD UNIT 20254
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-9012
Mailing Address - Country:US
Mailing Address - Phone:813-210-4098
Mailing Address - Fax:
Practice Address - Street 1:4125 TARTAN PL
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-5411
Practice Address - Country:US
Practice Address - Phone:813-210-4098
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities