Support Independent Living

Primary specialty

Developmental Disabilities Clinic/CenterTaxonomy code 261QD1600X

Legal business name

SUPPORT INDEPENDENT LIVING

Doing business as

support independent living

Practice address

11 Racetrack Rd NE Ste C2
Fort Walton Beach, FL 32547-1867

Phone

(850) 259-7190

NPI assigned

Feb 9, 2022

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Brenda F Marrier

Title

Owner

Phone

(850) 259-7190

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• support independent living Doing business as

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1644364800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1644364800000",
    "number": "1306590260",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11 RACETRACK RD NE STE C2",
            "city": "FORT WALTON BEACH",
            "state": "FL",
            "postal_code": "325471867",
            "telephone_number": "850-259-7190",
            "fax_number": "850-862-4849"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11 RACETRACK RD NE STE C2",
            "city": "FORT WALTON BEACH",
            "state": "FL",
            "postal_code": "325471867",
            "telephone_number": "850-259-7190"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SUPPORT INDEPENDENT LIVING",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-02-09",
        "last_updated": "2022-02-09",
        "certification_date": "2022-02-09",
        "status": "A",
        "authorized_official_last_name": "MARRIER",
        "authorized_official_first_name": "BRENDA",
        "authorized_official_middle_name": "F",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "850-259-7190"
    },
    "taxonomies": [
        {
            "code": "261QD1600X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Developmental Disabilities",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "684509696",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "support independent living",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Developmental Disabilities Clinic/Center in Fort Walton Beach, FL
• Providers in Fort Walton Beach, FL by specialty
• Developmental Disabilities Clinic/Center in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 9, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.