Organization
LIBRA 85
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JACEK DYGDON (OWNER)
(386) 315-0899
Entity
Organization
Contact information
Practice address
624 S ATLANTIC AVE, DAYTONA BEACH, FL 32118-4510
(386) 315-0899
Mailing address
624 S ATLANTIC AVE, DAYTONA BEACH, FL 32118-4510
Taxonomy
Speciality
Code
Description
License number
State
323P00000X
Psychiatric Residential Treatment Facility
Primary
AL5675
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004518600
—
FL
Enumeration date
02/25/2014
Last updated
02/25/2014
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