MEDICARE: COLANDTAL ENTERPRISES, INC

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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1790910792
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLANDTAL ENTERPRISES, INC

Provider Business Mailing Address
First Line	:	PO BOX 341123
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33694-1123
Country	:	US
Telephone Number	:	813-269-2273
Fax Number	:	813-269-2283

Provider Business Practice Location Address
First Line	:	5121 EHRLICH RD
Second Line	:	BLDG 101, SUITE G
City	:	TAMPA
State	:	FL
Zip	:	33624-2015
Country	:	US
Telephone Number	:	813-269-2273
Fax Number	:	813-269-2283

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. COLLIN DE GOURVILLE
Credential	:
Telephone Number	:	813-269-2273

Provider Enumeration Date	:	05/19/2009
Last Update Date	:	06/16/2009

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