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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