Provider Demographics
NPI:1093875650
Name:AGENCY FOR PERSONS WITH DISABILITIES
Entity Type:Organization
Organization Name:AGENCY FOR PERSONS WITH DISABILITIES
Other - Org Name:SUNLAND CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:EGELSTON
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:850-482-9210
Mailing Address - Street 1:3700 WILLIAMS DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446
Mailing Address - Country:US
Mailing Address - Phone:850-482-9220
Mailing Address - Fax:850-718-0434
Practice Address - Street 1:3700 WILLIAMS DRIVE
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446
Practice Address - Country:US
Practice Address - Phone:850-482-9220
Practice Address - Fax:850-718-0434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011996204Medicaid
FL011996204Medicaid