Basic Information
| Provider Information | |||||||||
| NPI: | 1346287240 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OSCEOLA MENTAL HEALTH INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PARK PLACE BEHAVIORAL HEALTH CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 PARK PLACE BLVD | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347412344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078460023 | ||||||||
| FaxNumber: | 4074831064 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 PARK PLACE BLVD | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347412344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078460023 | ||||||||
| FaxNumber: | 4074831064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 04/15/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARLOW | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT CFO | ||||||||
| AuthorizedOfficialTelephone: | 4078460023 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | FL | N | Agencies | Case Management | 320800000X | FL | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 251S00000X | FL | N | Agencies | Community/Behavioral Health | 261QM0801X | 8503 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 060313900 | 05 | FL | MEDICAID | 10D0870885 | 01 | FL | CLIA NUMBER | OTHER |