Healthcare Provider Details

I. General information

NPI: 1649032889
Provider Name (Legal Business Name): PCAH GUSHUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2024
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 S PATRICK DR # A3
SATELLITE BEACH FL
32937-3963
US

IV. Provider business mailing address

1275 S PATRICK DR # A3
SATELLITE BEACH FL
32937-3963
US

V. Phone/Fax

Practice location:
  • Phone: 321-329-5300
  • Fax: 321-329-5300
Mailing address:
  • Phone: 321-329-5300
  • Fax: 321-329-5300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. FRED GUSHUE JR.
Title or Position: CEO
Credential:
Phone: 321-329-5300