Healthcare Provider Details

I. General information

NPI: 1710322888
Provider Name (Legal Business Name): SHALLOMSTAR HEALTHCARE AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 05/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 BARANOVA RD
OCOEE FL
34761-1867
US

IV. Provider business mailing address

PO BOX 1222
OCOEE FL
34761-1222
US

V. Phone/Fax

Practice location:
  • Phone: 407-443-6703
  • Fax: 407-347-3692
Mailing address:
  • Phone: 407-443-6703
  • Fax: 407-347-3692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number232509
License Number StateFL

VIII. Authorized Official

Name: MRS. RITHE F. LEON
Title or Position: MANAGER
Credential:
Phone: 407-443-6703