Healthcare Provider Details

I. General information

NPI: 1942927694
Provider Name (Legal Business Name): NETTIE MAE BERRY FOUNDATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 NW 8TH AVE STE A2
GAINESVILLE FL
32601-5000
US

IV. Provider business mailing address

PO BOX 358774
GAINESVILLE FL
32635-8774
US

V. Phone/Fax

Practice location:
  • Phone: 352-258-3450
  • Fax: 352-379-5502
Mailing address:
  • Phone: 352-258-3450
  • Fax: 352-379-5502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. TANDRA LAMIKIA SIMMONS
Title or Position: CEO
Credential:
Phone: 352-258-3450