Healthcare Provider Details

I. General information

NPI: 1982017497
Provider Name (Legal Business Name): ADDIE'S ADULT FAMILY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7608 COPELAND RD
ODESSA FL
33556-3205
US

IV. Provider business mailing address

7608 COPELAND RD
ODESSA FL
33556-3205
US

V. Phone/Fax

Practice location:
  • Phone: 813-778-8245
  • Fax:
Mailing address:
  • Phone: 813-778-8245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number6906678
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number234669
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number234669
License Number StateFL

VIII. Authorized Official

Name: MS. MICHELE CELESTINE JAMES
Title or Position: ADMISTRATOR
Credential:
Phone: 813-778-2845