Provider Demographics
NPI:1285397471
Name:ESP CASE MANAGEMENT PROFESSIONAL, INC
Entity type:Organization
Organization Name:ESP CASE MANAGEMENT PROFESSIONAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:FAGARAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-760-7533
Mailing Address - Street 1:687 BEVILLE RD STE A
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-1970
Mailing Address - Country:US
Mailing Address - Phone:386-760-7533
Mailing Address - Fax:386-761-5868
Practice Address - Street 1:687 BEVILLE RD STE A
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-1970
Practice Address - Country:US
Practice Address - Phone:386-760-7533
Practice Address - Fax:386-761-5868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-15
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110146900Medicaid