NPIMap

Organization Active NPI

Florida Mentor II LLC

Doing business as Fort Walton Beach Developmental Center

  • Intellectual Disabilities Intermediate Care Facility
  • Fort Walton Beach, FL
National Provider Identifier
1962009019
Registry record updated Nov 18, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
Legal business name
FLORIDA MENTOR II LLC
Doing business as
Fort Walton Beach Developmental Center
Practice address
1045 Mar Walt Dr
Fort Walton Beach, FL 32547-6738
Phone
(850) 862-0108
Fax
(850) 862-7103
NPI assigned
Oct 1, 2020
Last updated
Nov 18, 2020By the provider in NPPES
Organization subpart
Yes
Parent organization
FLORIDA MENTOR II LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 18, 2020

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

Authorized official

Name
Carol Swanson
Title
Vice President of Operations
Phone
(813) 389-8300

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X Primary

Addresses

Primary practice location

1045 Mar Walt Dr
Fort Walton Beach, FL 32547-6738

Mailing address

3258 Parkside Center Cir
Tampa, FL 33619-0907
Phone (813) 389-8300

Other names 1

  • Fort Walton Beach Developmental Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1962009019. Details of each certification follow.

  • CCN 10G047 Intermediate care facility for individuals with intellectual disabilities · Active · Name & address match · Details

Intermediate care facility for individuals with intellectual disabilities certification: CCN 10G047

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
FORT WALTON BEACH DEVELOPMENTAL CENTER
Certification status
Active
Provider type (POS)
Intermediate care facility for individuals with intellectual disabilities
Participating since
Aug 5, 1982
Last certification
Mar 13, 2025
Beds
63
Ownership / control type
Private (proprietary)
Facility address
1045 Mar Walt Drive
Fort Walton Beach, FL 32547

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
10D0860494Florida Mentor II LLC1045 Mar Walt Dr, Fort Walton Beach, FL 32547Certificate of waiverAug 31, 2026

National Provider Directory

National Provider Directory
Tax ID family
Florida Mentor II LLC12 organizations share this tax ID, including this one
Part of
Florida Mentor II LLC

Other organizations with this tax ID 11

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

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

{
    "created_epoch": "1601510400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1605657600000",
    "number": "1962009019",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3258 PARKSIDE CENTER CIR",
            "city": "TAMPA",
            "state": "FL",
            "postal_code": "336190907",
            "telephone_number": "813-389-8300"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1045 MAR WALT DR",
            "city": "FORT WALTON BEACH",
            "state": "FL",
            "postal_code": "325476738",
            "telephone_number": "850-862-0108",
            "fax_number": "850-862-7103"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FLORIDA MENTOR II LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "FLORIDA MENTOR II LLC",
        "enumeration_date": "2020-10-01",
        "last_updated": "2020-11-18",
        "certification_date": "2020-11-18",
        "status": "A",
        "authorized_official_last_name": "SWANSON",
        "authorized_official_first_name": "CAROL",
        "authorized_official_title_or_position": "VICE PRESIDENT OF OPERATIONS",
        "authorized_official_telephone_number": "813-389-8300"
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Fort Walton Beach Developmental Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fort Walton Beach, FL

Sources for this page

Verify at the official NPI Registry.