Provider Demographics
NPI:1558446963
Name:CENTRAL FLORIDA CHILD HEALTH PROGRAM
Entity Type:Organization
Organization Name:CENTRAL FLORIDA CHILD HEALTH PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROJECT ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHLEEN
Authorized Official - Middle Name:O
Authorized Official - Last Name:MARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-858-6143
Mailing Address - Street 1:7040 LAKE ELLENOR DRIVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-5750
Mailing Address - Country:US
Mailing Address - Phone:407-858-6143
Mailing Address - Fax:407-856-6594
Practice Address - Street 1:7040 LAKE ELLENOR DRIVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-5750
Practice Address - Country:US
Practice Address - Phone:407-858-6143
Practice Address - Fax:407-856-6594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL056105302Medicaid