Healthcare Provider Details

I. General information

NPI: 1356827281
Provider Name (Legal Business Name): SKY LIMITS 75 INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2018
Last Update Date: 07/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 N COCOA BLVD STE 102
COCOA FL
32922-7582
US

IV. Provider business mailing address

950 N COCOA BLVD STE 102
COCOA FL
32922-7582
US

V. Phone/Fax

Practice location:
  • Phone: 184-365-5586
  • Fax: 321-632-0673
Mailing address:
  • Phone: 184-365-5586
  • Fax: 321-632-0673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number30211419
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number30211419
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: ANTWON MONTAE TRICE
Title or Position: PRESIDENT
Credential: SPECIALIST
Phone: 843-655-5860