Provider Demographics
NPI:1134285141
Name:FLORIDA MENTOR
Entity Type:Organization
Organization Name:FLORIDA MENTOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:DEMETRICE
Authorized Official - Last Name:MONAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-274-4172
Mailing Address - Street 1:1725 FIFTH ST
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5107
Mailing Address - Country:US
Mailing Address - Phone:386-274-4172
Mailing Address - Fax:386-274-5568
Practice Address - Street 1:1725 5TH STREET
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5107
Practice Address - Country:US
Practice Address - Phone:386-274-4172
Practice Address - Fax:386-274-5568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL03125760251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services