Provider Demographics
NPI:1235314915
Name:FLORRY CREATIVE CARE CORPORATION
Entity Type:Organization
Organization Name:FLORRY CREATIVE CARE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERRY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:HALLBACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-650-8242
Mailing Address - Street 1:PO BOX 5636
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-0047
Mailing Address - Country:US
Mailing Address - Phone:813-650-8242
Mailing Address - Fax:813-650-8242
Practice Address - Street 1:415 N WILDER RD
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33566-7544
Practice Address - Country:US
Practice Address - Phone:813-441-4761
Practice Address - Fax:866-240-5666
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FORRY CREATIVE CARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-31
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X, 3104A0625X
FLAL118253104A0625X
FL692691696311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002437100Medicaid
FL104395400Medicaid
FL6292691696Medicaid