Provider Demographics
NPI:1598069718
Name:SOCIETY OF ST. AGNES
Entity Type:Organization
Organization Name:SOCIETY OF ST. AGNES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ATUKUZWE
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:NYIRENDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-644-6640
Mailing Address - Street 1:PO BOX 7422
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33807-7422
Mailing Address - Country:US
Mailing Address - Phone:863-644-6640
Mailing Address - Fax:863-709-0595
Practice Address - Street 1:6012 CASON WAY
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812-3888
Practice Address - Country:US
Practice Address - Phone:863-644-6640
Practice Address - Fax:863-709-0595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14GH01357251C00000X
FL14GH01351251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services