Provider Demographics
NPI:1326183377
Name:EASTERSEALS NORTHEAST CENTRAL FLORIDA
Entity type:Organization
Organization Name:EASTERSEALS NORTHEAST CENTRAL FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-255-4568
Mailing Address - Street 1:1219 DUNN AVE
Mailing Address - Street 2:P.O. BOX 9117
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2405
Mailing Address - Country:US
Mailing Address - Phone:386-255-4568
Mailing Address - Fax:386-258-7677
Practice Address - Street 1:650 W NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-5239
Practice Address - Country:US
Practice Address - Phone:386-255-4568
Practice Address - Fax:386-258-7677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL34167261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8907811 00Medicaid