Healthcare Provider Details

I. General information

NPI: 1508475476
Provider Name (Legal Business Name): FULL CIRCLE OF LOVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
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: 239-240-6721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

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