Provider Demographics
NPI:1265966857
Name:ENVISIONLIFESERVICES,LLC
Entity type:Organization
Organization Name:ENVISIONLIFESERVICES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHILANDER
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:HEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-510-0915
Mailing Address - Street 1:PO BOX 105
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32302-0105
Mailing Address - Country:US
Mailing Address - Phone:850-510-0915
Mailing Address - Fax:
Practice Address - Street 1:404 EL DESTINADO DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32312-1607
Practice Address - Country:US
Practice Address - Phone:850-510-0915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities