Healthcare Provider Details

I. General information

NPI: 1003458910
Provider Name (Legal Business Name): CLEAN COOKIE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6518 STONE RD
PORT RICHEY FL
34668-4860
US

IV. Provider business mailing address

6518 STONE RD
PORT RICHEY FL
34668-4860
US

V. Phone/Fax

Practice location:
  • Phone: 727-225-6286
  • Fax:
Mailing address:
  • Phone: 727-225-6286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health 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: TIA KETTER
Title or Position: RN
Credential:
Phone: 727-225-6286