Organization
SUPPORT INDEPENDENT LIVING
Active
Other names
support independent living
Organization subpart
No
Provider details
NPI number
Authorized official
BRENDA F MARRIER (OWNER)
(850) 259-7190
Entity
Organization
Contact information
Practice address
11 RACETRACK RD NE STE C2, FORT WALTON BEACH, FL 32547-1867
(850) 259-7190
Mailing address
11 RACETRACK RD NE STE C2, FORT WALTON BEACH, FL 32547-1867
(850) 259-7190
(850) 862-4849
Taxonomy
Speciality
Code
Description
License number
State
261QD1600X
Developmental Disabilities Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
684509696
—
FL
Enumeration date
02/09/2022
Last updated
02/09/2022
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