Provider Demographics
NPI:1265196661
Name:PANSY'S PLACE
Entity type:Organization
Organization Name:PANSY'S PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHEMIA
Authorized Official - Middle Name:TIERRE
Authorized Official - Last Name:PRINCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-287-0308
Mailing Address - Street 1:1905 W BLUE HERON BLVD
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404-5149
Mailing Address - Country:US
Mailing Address - Phone:561-287-0305
Mailing Address - Fax:567-247-7627
Practice Address - Street 1:2058 PINEHURST DR
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-3546
Practice Address - Country:US
Practice Address - Phone:561-287-0305
Practice Address - Fax:561-247-7627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities