Basic Information
| Provider Information | |||||||||
| NPI: | 1235213216 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH CARE CENTER FOR THE HOMELESS INC | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ORANGE BLOSSOM FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 232 N ORANGE BLOSSOM TRL | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328051612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074285751 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 232 N ORANGE BLOSSOM TRL | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328051612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074285751 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | BURNS | ||||||||
| AuthorizedOfficialFirstName: | BAKARI | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4074285751 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MPH, MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | BUS0009641-003 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 687429100 | 05 | FL | MEDICAID | 687429101 | 05 | FL | MEDICAID | 687429102 | 05 | FL | MEDICAID | 5000-127026 | 01 | FL | ORANGE COUNTY BUSINESS LI | OTHER | BUS0009641-0003 | 01 | FL | CITY OF ORLANDO BUSINESS | OTHER |