Organization Name: | BREAKWATER ADULT FAMILY CARE HOME LLC |
NPI Number: | 1356407704 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | VINCE JACOBS (OWNER) |
Mailing Address: | 22699 Sw Breakwater Blvd Dunnellon |
State: | FL US |
Postal Code: | 344314039 |
Phone Number: | 3524017699 |
Fax Number: | 3524017698 |
NPI Enumeration Date: | 12/29/2006 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 320900000X |
License Number: | 6905655 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | FL |
Taxonomy Type: | Residential Treatment Facilities |
Taxonomy Classification: | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
Taxonomy Specialization: | |
Taxonomy Definition: | A home-like residential facility providing habilitation, support and monitoring services to individuals diagnosed with mental retardation and/or developmental disabilities. |