Organization
WINGS OF LOVE OF LEESBURG, LLC
Active
Organization
WINGS OF LOVE OF LEESBURG, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. PERNELL MITCHELL (PRESIDENT)
(352) 360-0660
Entity
Organization
Contact information
Practice address
1018 W NORTH BLVD, LEESBURG, FL 34748-5057
(352) 360-0660
(352) 360-0567
Mailing address
PO BOX 491077, LEESBURG, FL 34749-1077
(352) 360-0660
(352) 360-0567
Taxonomy
Speciality
Code
Description
License number
State
251C00000X
Developmentally Disabled Services Day Training Agency
Primary
688587096
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
688587096
MEDWAIVER PROVIDER NUMBER
FL
01
—
688587098
FAMILY & SUPPORT LIVING WAIVER
FL
01
—
F342051880001
VENDOR NUMBER
FL
Enumeration date
05/20/2008
Last updated
05/20/2008
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