Provider Demographics
NPI: | 1730285883 |
---|---|
Name: | MEDIVAN HEALTH AND COMMUNITY SERVICES, INC. |
Entity Type: | Organization |
Organization Name: | MEDIVAN HEALTH AND COMMUNITY SERVICES, INC. |
Other - Org Name: | MEDIVAN PROJECT |
Other - Org Type: | Other Name |
Authorized Official - Title/Position: | EXECUTIVE DIRECTOR |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | SHARON |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | ROSS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | RN, DPA |
Authorized Official - Phone: | 954-735-9019 |
Mailing Address - Street 1: | 5101 NW 21ST AVE |
Mailing Address - Street 2: | SUITE 510 |
Mailing Address - City: | FORT LAUDERDALE |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33309-2792 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 954-735-9019 |
Mailing Address - Fax: | 954-733-9315 |
Practice Address - Street 1: | 5101 NW 21ST AVE |
Practice Address - Street 2: | SUITE 510 |
Practice Address - City: | FORT LAUDERDALE |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33309-2792 |
Practice Address - Country: | US |
Practice Address - Phone: | 954-735-9019 |
Practice Address - Fax: | 954-733-9315 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-09-16 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251V00000X | Agencies | Voluntary or Charitable |