Provider Demographics
NPI:1184902157
Name:WADE, DAVID CHRISTOPHER
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:CHRISTOPHER
Last Name:WADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4623 EBONY ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-3823
Mailing Address - Country:US
Mailing Address - Phone:407-990-6333
Mailing Address - Fax:321-206-4502
Practice Address - Street 1:4623 EBONY ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-3823
Practice Address - Country:US
Practice Address - Phone:407-990-6333
Practice Address - Fax:321-206-4502
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-25
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL310400000X, 3104A0625X
372600000X
FL007902900251E00000X
FL003905100251E00000X
FL232909376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No372600000XNursing Service Related ProvidersAdult Companion
No251E00000XAgenciesHome Health
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007902900Medicaid