Provider Demographics
NPI:1053470385
Name:DEVEREUX FOUNDATION, INC.
Entity Type:Organization
Organization Name:DEVEREUX FOUNDATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NATIONAL DIRECTOR OF ACCOUNTS RECEI
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:LYLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-637-4536
Mailing Address - Street 1:5850 T.G. LEE BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822
Mailing Address - Country:US
Mailing Address - Phone:407-362-9210
Mailing Address - Fax:
Practice Address - Street 1:3350 STATE ROAD 60 E
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-8471
Practice Address - Country:US
Practice Address - Phone:813-460-4451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029573603Medicaid