Provider Demographics
NPI:1558618454
Name:BRAIN DISORDER SUPPORT FOUNDATION, INC.
Entity Type:Organization
Organization Name:BRAIN DISORDER SUPPORT FOUNDATION, INC.
Other - Org Name:FRIENDSHIP HOUSE BDSF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOT
Authorized Official - Prefix:MRS
Authorized Official - First Name:HILDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:COURSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-892-0565
Mailing Address - Street 1:353 JUNIPER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32433-3514
Mailing Address - Country:US
Mailing Address - Phone:850-892-0565
Mailing Address - Fax:850-520-4651
Practice Address - Street 1:353 JUNIPER LAKE RD
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32433-3514
Practice Address - Country:US
Practice Address - Phone:850-892-0565
Practice Address - Fax:850-520-4651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAHCA #9115261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9115OtherFL AHCA LICENSE