Healthcare Provider Details

I. General information

NPI: 1518629922
Provider Name (Legal Business Name): FULL CIRCLE OF LOVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2021
Last Update Date: 10/13/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 SW TRAFALGAR PKWY
CAPE CORAL FL
33991-3489
US

IV. Provider business mailing address

105 SW TRAFALGAR PKWY
CAPE CORAL FL
33991-3489
US

V. Phone/Fax

Practice location:
  • Phone: 239-240-6721
  • Fax:
Mailing address:
  • Phone: 123-924-0672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name: TAYLISA JOHNSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 239-240-6721