Provider Demographics
NPI:1962250233
Name:SUPPORTING INDIVIDUALS WITH DISABILITIES INC
Entity type:Organization
Organization Name:SUPPORTING INDIVIDUALS WITH DISABILITIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:D
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-507-9976
Mailing Address - Street 1:95129 SPRINGHILL RD
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-9410
Mailing Address - Country:US
Mailing Address - Phone:904-507-9976
Mailing Address - Fax:
Practice Address - Street 1:95129 SPRINGHILL RD
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-9410
Practice Address - Country:US
Practice Address - Phone:904-507-9976
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child