Provider Demographics
NPI:1538228861
Name:DEVEREUX FOUNDATION
Entity type:Organization
Organization Name:DEVEREUX FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-362-9210
Mailing Address - Street 1:5850 T.G. LEE BOULEVARD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822
Mailing Address - Country:US
Mailing Address - Phone:407-812-4555
Mailing Address - Fax:
Practice Address - Street 1:8000 DEVEREUX DR
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-7907
Practice Address - Country:US
Practice Address - Phone:321-242-9100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029573629Medicaid