Provider Demographics
NPI:1528417391
Name:FLORRY CREATIVE CARE
Entity Type:Organization
Organization Name:FLORRY CREATIVE CARE
Other - Org Name:TRUDIE'S HAVEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERRY
Authorized Official - Middle Name:
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:
Practice Address - Street 1:1404 HOLLOMAN RD
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33567-3706
Practice Address - Country:US
Practice Address - Phone:813-650-8242
Practice Address - Fax:866-240-5666
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORRY CREATIVE CARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-12
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL128473104A0625X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL692691696Medicaid