Provider Demographics
NPI:1801142393
Name:CENTER FOR INDEPENDENT LIVING OF NORTH CENTRAL FLORIDA
Entity type:Organization
Organization Name:CENTER FOR INDEPENDENT LIVING OF NORTH CENTRAL FLORIDA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:III
Authorized Official - Credentials:MHS
Authorized Official - Phone:352-378-7474
Mailing Address - Street 1:222 SW 36TH TER
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-2863
Mailing Address - Country:US
Mailing Address - Phone:352-378-7474
Mailing Address - Fax:352-378-5582
Practice Address - Street 1:222 SW 36TH TER
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2863
Practice Address - Country:US
Practice Address - Phone:352-378-7474
Practice Address - Fax:352-378-5582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003148100Medicaid