Healthcare Provider Details

I. General information

NPI: 1124751847
Provider Name (Legal Business Name): INGRID M THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2022
Last Update Date: 07/09/2022
Certification Date: 07/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 E MAGNOLIA AVE STE 3B
EUSTIS FL
32726-3472
US

IV. Provider business mailing address

15 E MAGNOLIA AVE STE 3B
EUSTIS FL
32726-3472
US

V. Phone/Fax

Practice location:
  • Phone: 352-617-0777
  • Fax: 352-251-1911
Mailing address:
  • Phone: 352-617-0777
  • Fax: 352-251-1911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: