Provider Demographics
NPI:1528326758
Name:SPACE COAST CENTER FOR INDEPENDENT LIVING
Entity type:Organization
Organization Name:SPACE COAST CENTER FOR INDEPENDENT LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:L
Authorized Official - Last Name:DUNHAM-SCHULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-633-6011
Mailing Address - Street 1:571 HAVERTY CT STE W
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3614
Mailing Address - Country:US
Mailing Address - Phone:321-633-6011
Mailing Address - Fax:321-633-6472
Practice Address - Street 1:571 HAVERTY CT STE W
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3614
Practice Address - Country:US
Practice Address - Phone:321-633-6011
Practice Address - Fax:321-633-6472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003421900Medicaid