Provider Demographics
NPI:1780913103
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:
Authorized Official - Last Name:DUNHAM-CESARIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-633-6011
Mailing Address - Street 1:803 N FISKE BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-7323
Mailing Address - Country:US
Mailing Address - Phone:321-633-6011
Mailing Address - Fax:
Practice Address - Street 1:803 N FISKE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7323
Practice Address - Country:US
Practice Address - Phone:321-633-6011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management