Provider Demographics
NPI:1073922605
Name:POTENTIEL ILLIMITE CORP
Entity Type:Organization
Organization Name:POTENTIEL ILLIMITE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOZONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-588-5135
Mailing Address - Street 1:13220 SCHARBER RD
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33525-8008
Mailing Address - Country:US
Mailing Address - Phone:352-588-5135
Mailing Address - Fax:352-588-5135
Practice Address - Street 1:13220 SCHARBER RD
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-8008
Practice Address - Country:US
Practice Address - Phone:352-588-5135
Practice Address - Fax:352-588-5135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW88511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty