Provider Demographics
NPI:1770832941
Name:WHITE FAMILY CARE HOME
Entity Type:Organization
Organization Name:WHITE FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ OPERATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ETHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE
Authorized Official - Phone:407-365-9110
Mailing Address - Street 1:4859 PUBLIX ROAD
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765
Mailing Address - Country:US
Mailing Address - Phone:407-365-9110
Mailing Address - Fax:407-542-7301
Practice Address - Street 1:4859 PUBLIX ROAD
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765
Practice Address - Country:US
Practice Address - Phone:407-365-9110
Practice Address - Fax:407-542-7301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6905109320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL141522100Medicaid