Healthcare Provider Details

I. General information

NPI: 1205581402
Provider Name (Legal Business Name): IVORY HOMECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4630 LIPSCOMB ST NE STE 15
PALM BAY FL
32905-2940
US

IV. Provider business mailing address

4300 N UNIVERSITY DR SUITE F100
SUNRISE FL
33351-6249
US

V. Phone/Fax

Practice location:
  • Phone: 754-354-0402
  • Fax:
Mailing address:
  • Phone: 754-354-0402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: FEDNA GUILLAUME
Title or Position: PRESIDENT
Credential:
Phone: 754-354-0402