Provider Demographics
NPI:1992406607
Name:EASTERSEALS NORTHEAST CENTRAL FLORIDA, INC.
Entity type:Organization
Organization Name:EASTERSEALS NORTHEAST CENTRAL FLORIDA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-255-4568
Mailing Address - Street 1:1219 DUNN AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2405
Mailing Address - Country:US
Mailing Address - Phone:386-944-7805
Mailing Address - Fax:386-258-7677
Practice Address - Street 1:3804 PIONEER TRL
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-8784
Practice Address - Country:US
Practice Address - Phone:386-944-7805
Practice Address - Fax:386-258-7677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty