Healthcare Provider Details

I. General information

NPI: 1831648930
Provider Name (Legal Business Name): FOUR NINETEEN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2016
Last Update Date: 09/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9015 TOWN CENTER PKWY #104
LAKEWOOD RANCH FL
34202-5012
US

IV. Provider business mailing address

9015 TOWN CENTER PKWY #104
LAKEWOOD RANCH FL
34202-5012
US

V. Phone/Fax

Practice location:
  • Phone: 941-920-0826
  • Fax:
Mailing address:
  • Phone: 941-920-0826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number299994641
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. HENRY BERNARD HAITZ III
Title or Position: OWNER
Credential:
Phone: 941-920-0826