Provider Demographics
NPI:1487893095
Name:A .L. PANTAGES INC.
Entity type:Organization
Organization Name:A .L. PANTAGES INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:LOU
Authorized Official - Last Name:PANTAGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-673-3255
Mailing Address - Street 1:1321 RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLY HILL
Mailing Address - State:FL
Mailing Address - Zip Code:32117-2319
Mailing Address - Country:US
Mailing Address - Phone:386-673-3255
Mailing Address - Fax:
Practice Address - Street 1:1321 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:FL
Practice Address - Zip Code:32117-2319
Practice Address - Country:US
Practice Address - Phone:386-673-3255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAD8854251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL675582896Medicaid
FL675582898Medicaid
FL675582800Medicaid