Provider Demographics
NPI:1730316688
Name:COUNTRY ACRES GROUP HOME
Entity Type:Organization
Organization Name:COUNTRY ACRES GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR HOUSING HUMAN SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-264-5000
Mailing Address - Street 1:1850 S DELEON AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-7733
Mailing Address - Country:US
Mailing Address - Phone:321-264-5000
Mailing Address - Fax:321-264-5195
Practice Address - Street 1:1850 S DELEON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-7733
Practice Address - Country:US
Practice Address - Phone:321-264-5000
Practice Address - Fax:321-264-5195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18-1073-025-08253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency