Provider Demographics
NPI:1114535291
Name:SOVEREIGN DEVELOPMENTAL CENTER
Entity Type:Organization
Organization Name:SOVEREIGN DEVELOPMENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AREA DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:
Authorized Official - Last Name:AUGUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-271-4208
Mailing Address - Street 1:12553 NEW BRITTANY BLVD BLDG 32
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3625
Mailing Address - Country:US
Mailing Address - Phone:239-257-5300
Mailing Address - Fax:
Practice Address - Street 1:12553 NEW BRITTANY BLVD BLDG 32
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3625
Practice Address - Country:US
Practice Address - Phone:239-257-5300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health