Provider Demographics
NPI:1679734396
Name:NETTIE MAE BERRY FOUNDATION LLC
Entity Type:Organization
Organization Name:NETTIE MAE BERRY FOUNDATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TANDRA
Authorized Official - Middle Name:LAIMIKIA
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-258-3450
Mailing Address - Street 1:113 NE 39TH PL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32609-1717
Mailing Address - Country:US
Mailing Address - Phone:352-258-3450
Mailing Address - Fax:352-376-5474
Practice Address - Street 1:113 NE 39TH PL
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-1717
Practice Address - Country:US
Practice Address - Phone:352-258-3450
Practice Address - Fax:352-376-5474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL689678298251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL689678298Medicaid