Healthcare Provider Details

I. General information

NPI: 1558653204
Provider Name (Legal Business Name): SUPPORTING INDEPENDENCE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2011
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 LUCIEN WAY SUITE 175
MAITLAND FL
32751-7007
US

IV. Provider business mailing address

2200 LUCIEN WAY SUITE 175
MAITLAND FL
32751
US

V. Phone/Fax

Practice location:
  • Phone: 407-434-0766
  • Fax: 407-434-0766
Mailing address:
  • Phone: 407-434-0766
  • Fax: 407-434-0766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number299993995
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number299993995
License Number StateFL

VIII. Authorized Official

Name: MR. CHRIS PARK
Title or Position: OWNER
Credential:
Phone: 407-434-0766