Provider Demographics
NPI:1972902096
Name:MAVIS HINSON ADULT FAMILY CARE HOME
Entity type:Organization
Organization Name:MAVIS HINSON ADULT FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:MAVIS
Authorized Official - Middle Name:ERNESTINE
Authorized Official - Last Name:HINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-460-8498
Mailing Address - Street 1:600 SOUTH 10TH STREET
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-8516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 SOUTH 10TH STREET
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-8516
Practice Address - Country:US
Practice Address - Phone:772-460-8498
Practice Address - Fax:772-460-8498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906464311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home