Provider Demographics
NPI:1770071953
Name:ASGARD AGENCY
Entity type:Organization
Organization Name:ASGARD AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTANZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-551-7730
Mailing Address - Street 1:4501 3RD AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-1017
Mailing Address - Country:US
Mailing Address - Phone:954-551-7730
Mailing Address - Fax:
Practice Address - Street 1:6109 W KNIGHTS GRIFFIN RD
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33565-3717
Practice Address - Country:US
Practice Address - Phone:954-551-7730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services