Provider Demographics
NPI:1356764823
Name:EXTENDED FAMILY ALR INC
Entity type:Organization
Organization Name:EXTENDED FAMILY ALR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:386-957-3907
Mailing Address - Street 1:2505 W LAKE DR
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-3245
Mailing Address - Country:US
Mailing Address - Phone:386-957-3907
Mailing Address - Fax:386-957-6316
Practice Address - Street 1:1020 CLAUDIA ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-6354
Practice Address - Country:US
Practice Address - Phone:386-957-3907
Practice Address - Fax:386-957-6316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12247320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities