Provider Demographics
NPI:1700663606
Name:INTENTIONAL PROVISIONS OUTREACH CORPORATION
Entity type:Organization
Organization Name:INTENTIONAL PROVISIONS OUTREACH CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECT CARE
Authorized Official - Prefix:
Authorized Official - First Name:SHANDRA
Authorized Official - Middle Name:P
Authorized Official - Last Name:MALLARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-239-3081
Mailing Address - Street 1:1799 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-6621
Mailing Address - Country:US
Mailing Address - Phone:786-239-3081
Mailing Address - Fax:
Practice Address - Street 1:1799 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-6621
Practice Address - Country:US
Practice Address - Phone:786-239-3081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities