Provider Demographics
NPI:1558664078
Name:AMBER PLACE
Entity Type:Organization
Organization Name:AMBER PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:ANGELLA
Authorized Official - Last Name:WELLINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-489-6444
Mailing Address - Street 1:2365 W AMBER PL
Mailing Address - Street 2:
Mailing Address - City:CITRUS SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34434-4006
Mailing Address - Country:US
Mailing Address - Phone:352-489-6444
Mailing Address - Fax:352-489-6444
Practice Address - Street 1:2365 W AMBER PL
Practice Address - Street 2:
Practice Address - City:CITRUS SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34434-4006
Practice Address - Country:US
Practice Address - Phone:352-489-6444
Practice Address - Fax:352-489-6444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11222320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL692012896Medicaid