Healthcare Provider Details

I. General information

NPI: 1356781793
Provider Name (Legal Business Name): C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2013
Last Update Date: 06/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 CONCORD RD
TALLAHASSEE FL
32308-6217
US

IV. Provider business mailing address

PO BOX 413
TALLAHASSEE FL
32302-0413
US

V. Phone/Fax

Practice location:
  • Phone: 850-590-7361
  • Fax:
Mailing address:
  • Phone: 850-590-7361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number233070
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number233070
License Number StateFL

VIII. Authorized Official

Name: JASMINE ALEXANDRIA NUNNE
Title or Position: OWNER
Credential:
Phone: 850-590-7361