Provider Demographics
NPI:1831536515
Name:FLORIDA LIONS CONKLIN CTRS FOR THE BLIND
Entity type:Organization
Organization Name:FLORIDA LIONS CONKLIN CTRS FOR THE BLIND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:T
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:CRC
Authorized Official - Phone:386-258-3441
Mailing Address - Street 1:405 WHITE ST
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2925
Mailing Address - Country:US
Mailing Address - Phone:386-258-3441
Mailing Address - Fax:386-258-1155
Practice Address - Street 1:405 WHITE ST
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2925
Practice Address - Country:US
Practice Address - Phone:386-258-3441
Practice Address - Fax:386-258-1155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL099870202Medicaid
FL673361196Medicaid