Provider Demographics
NPI:1336478304
Name:SEQUEL TSI OF FLORIDA, LLC MARION PROGRAM
Entity Type:Organization
Organization Name:SEQUEL TSI OF FLORIDA, LLC MARION PROGRAM
Other - Org Name:MARION JUVENILE CORRECTIONAL FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:STUPAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-419-8913
Mailing Address - Street 1:10420 NW GAINESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34482-1446
Mailing Address - Country:US
Mailing Address - Phone:352-840-8240
Mailing Address - Fax:352-840-8256
Practice Address - Street 1:10420 NW GAINESVILLE RD
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34482-1446
Practice Address - Country:US
Practice Address - Phone:352-840-8240
Practice Address - Fax:352-840-8256
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SEQUEL TSI OF FLORIDA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
322D00000X
FL0542AD97093245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children