Provider Demographics
NPI:1346407111
Name:WINGS OF LOVE OF LEESBURG, LLC
Entity Type:Organization
Organization Name:WINGS OF LOVE OF LEESBURG, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PERNELL
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-360-0660
Mailing Address - Street 1:PO BOX 491077
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34749-1077
Mailing Address - Country:US
Mailing Address - Phone:352-360-0660
Mailing Address - Fax:352-360-0567
Practice Address - Street 1:1018 W NORTH BLVD
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5057
Practice Address - Country:US
Practice Address - Phone:352-360-0660
Practice Address - Fax:352-360-0567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL688587096251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF342051880001OtherVENDOR NUMBER
FL688587098OtherFAMILY & SUPPORT LIVING WAIVER
FL688587096OtherMEDWAIVER PROVIDER NUMBER