MEDICARE: SHANITTA KENYETTA GRIMSLEY HOME CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376J00000X	Homemaker

General Provider Information

NPI Number	:	1134853419
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANITTA KENYETTA GRIMSLEY HOME CARE LLC

Provider Business Mailing Address
First Line	:	1227 ARIANA ST
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33803-1814
Country	:	US
Telephone Number	:	813-638-3463
Fax Number	:

Provider Business Practice Location Address
First Line	:	1227 ARIANA ST
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33803-1814
Country	:	US
Telephone Number	:	813-638-3463
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2022
Last Update Date	:	07/13/2022

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