Provider Demographics
NPI:1710945118
Name:FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES
Entity Type:Organization
Organization Name:FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES
Other - Org Name:FLORIDA STATE HOSPITAL-UNIT 31
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HOSPITAL ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:LEWALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-663-7536
Mailing Address - Street 1:100 N MAIN ST
Mailing Address - Street 2:MEDICARE BILLING DEPT. BLDG 1260, 3RD FLOOR
Mailing Address - City:CHATTAHOOCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:32324-1107
Mailing Address - Country:US
Mailing Address - Phone:850-663-7802
Mailing Address - Fax:850-663-7516
Practice Address - Street 1:100 N MAIN ST
Practice Address - Street 2:UNIT 31, BLDG 1243
Practice Address - City:CHATTAHOOCHEE
Practice Address - State:FL
Practice Address - Zip Code:32324-1107
Practice Address - Country:US
Practice Address - Phone:850-663-7802
Practice Address - Fax:850-663-7516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3990282N00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104294700Medicaid
FL011978400Medicaid
FL270014000Medicaid
FL270014000Medicaid
FL100298Medicare Oscar/Certification