=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003518002
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUANITA COMPANION CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2023
-----------------------------------------------------
Last Update Date | 03/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1365 HELENA ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32208-3325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-517-3882
-----------------------------------------------------
Fax | 904-513-4985
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1365 HELENA ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32208-3325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-517-3882
-----------------------------------------------------
Fax | 904-513-4985
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AMBR
-----------------------------------------------------
Name | JOANNA L JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-517-3882
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------