Provider Demographics
NPI:1225278989
Name:AGENCY FOR PERSONS WITH DISABILITIES
Entity Type:Organization
Organization Name:AGENCY FOR PERSONS WITH DISABILITIES
Other - Org Name:SUNLAND COX MEDICAL SERVICES - DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLEMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-482-9222
Mailing Address - Street 1:3700 WILLIAMS DR
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-7973
Mailing Address - Country:US
Mailing Address - Phone:850-482-9222
Mailing Address - Fax:850-718-0434
Practice Address - Street 1:3700 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-7973
Practice Address - Country:US
Practice Address - Phone:850-482-9222
Practice Address - Fax:850-718-0434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-20
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QH0100X251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011996204Medicaid
FL97949Medicare PIN