Provider Demographics
NPI:1487278180
Name:TELFAIR, MARIO R
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:R
Last Name:TELFAIR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SHAD WAY
Mailing Address - Street 2:
Mailing Address - City:POINCIANA
Mailing Address - State:FL
Mailing Address - Zip Code:34759-4730
Mailing Address - Country:US
Mailing Address - Phone:727-492-3685
Mailing Address - Fax:
Practice Address - Street 1:301 SHAD WAY
Practice Address - Street 2:
Practice Address - City:POINCIANA
Practice Address - State:FL
Practice Address - Zip Code:34759-4730
Practice Address - Country:US
Practice Address - Phone:727-492-3685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-29
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6907018311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home