Provider Demographics
NPI:1902246200
Name:AMIKIDS ESCAMBIA BOY'S BASE
Entity Type:Organization
Organization Name:AMIKIDS ESCAMBIA BOY'S BASE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:OLIVER
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-453-7490
Mailing Address - Street 1:CORRY STATION CORRY FLD BLDG 3780
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32511-0001
Mailing Address - Country:US
Mailing Address - Phone:850-453-7490
Mailing Address - Fax:850-456-3749
Practice Address - Street 1:CORRY STATION CORRY FLD BLDG 3780
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32511-0001
Practice Address - Country:US
Practice Address - Phone:850-453-7490
Practice Address - Fax:850-456-3749
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMIKIDS PENSACOLA INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health