Provider Demographics
NPI:1356058762
Name:SPIRITUAL CONNECTION OUTREACH COMMUNITY CENTER OF SOUTH FLORIDA
Entity type:Organization
Organization Name:SPIRITUAL CONNECTION OUTREACH COMMUNITY CENTER OF SOUTH FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAIOLA
Authorized Official - Suffix:
Authorized Official - Credentials:CBHCMS
Authorized Official - Phone:917-567-0530
Mailing Address - Street 1:5975 W SUNRISE BVLD
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33313
Mailing Address - Country:US
Mailing Address - Phone:917-794-5972
Mailing Address - Fax:
Practice Address - Street 1:5975 W SUNRISE BVLD
Practice Address - Street 2:SUITE 210
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33313-1663
Practice Address - Country:US
Practice Address - Phone:917-567-0530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-04
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1619623451Medicaid