Healthcare Provider Details

I. General information

NPI: 1982880688
Provider Name (Legal Business Name): FLORIDA SENIOR CARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 01/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5910 CARRIAGE LAKE CT
VERO BEACH FL
32968-9476
US

IV. Provider business mailing address

PO BOX 691114
VERO BEACH FL
32969-1114
US

V. Phone/Fax

Practice location:
  • Phone: 772-559-8673
  • Fax: 772-564-8719
Mailing address:
  • Phone: 772-559-8673
  • Fax: 772-564-8719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberSW6243
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberSW6243
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberSW6243
License Number StateFL

VIII. Authorized Official

Name: MR. JERRY LLOYD TACKETT
Title or Position: VP BUSINESS DEVELOPMENT
Credential: M.ED., BA, BS, AAMS.
Phone: 772-559-8673