Provider Demographics
NPI:1609029636
Name:MICHAEL MCLEAN AND FRIENDS
Entity Type:Organization
Organization Name:MICHAEL MCLEAN AND FRIENDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:MCLEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-378-8286
Mailing Address - Street 1:1135 NW 23RD AVE
Mailing Address - Street 2:STE P
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32609
Mailing Address - Country:US
Mailing Address - Phone:352-378-8286
Mailing Address - Fax:352-378-4028
Practice Address - Street 1:1135 NW 23RD AVE STE P
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-3450
Practice Address - Country:US
Practice Address - Phone:352-378-8286
Practice Address - Fax:352-378-4028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL693622900Medicaid