Provider Demographics
NPI:1245398361
Name:AGENCY FOR PERSONS WITH DISABILITIES
Entity Type:Organization
Organization Name:AGENCY FOR PERSONS WITH DISABILITIES
Other - Org Name:GULF COAST CENTER ICF DD - STATE OF FL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CENTER ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MAYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-690-3652
Mailing Address - Street 1:5820 BUCKINGHAM ROAD
Mailing Address - Street 2:
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-7413
Mailing Address - Country:US
Mailing Address - Phone:239-694-2151
Mailing Address - Fax:239-694-6231
Practice Address - Street 1:5820 BUCKINGHAM ROAD
Practice Address - Street 2:
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7413
Practice Address - Country:US
Practice Address - Phone:239-690-3662
Practice Address - Fax:239-694-5802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0280089-00Medicaid
FL0280127-00Medicaid
FL0280224-00Medicaid
FL0280135-00Medicaid
FL0280178-00Medicaid
FL0280011-00Medicaid