Provider Demographics
NPI:1851715734
Name:APPETITE FOR LIFE
Entity Type:Organization
Organization Name:APPETITE FOR LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CELESTE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-470-9111
Mailing Address - Street 1:402 W CERVANTES ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-3032
Mailing Address - Country:US
Mailing Address - Phone:850-470-9111
Mailing Address - Fax:850-470-0201
Practice Address - Street 1:402 W CERVANTES ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-3032
Practice Address - Country:US
Practice Address - Phone:850-470-9111
Practice Address - Fax:850-470-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17481460283332U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332U00000XSuppliersHome Delivered Meals
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL677803800Medicaid
FL677803801Medicaid