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General NPI Number Information
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NPI Number | 1184592404
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Entity Type | Organization
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Legal Business Name | SUPPORTIVE SPACE HOME CARE
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Dates
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Enumeration Date | 10/28/2025
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Last Update Date | 11/18/2025
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Provider Practice Location Address
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Address Line | 352 TANGLEWOOD DR
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City | DAVENPORT
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State | FL
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Zip | 33896-3106
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Country | US
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Telephone | 317-473-0037
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Fax |
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Provider Business Mailing Address
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Address Line | 352 TANGLEWOOD DR
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City | DAVENPORT
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State | FL
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Zip | 33896-3106
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Country | US
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Telephone | 317-473-0037
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Fax |
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Authorized Official
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Title or Position | ADMIN
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Name | MONIQUE MARIE CANNON
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Credential | N/A
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Telephone | 317-473-0037
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 376J00000X
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Taxonomy Name | Homemaker
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License Number |
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License Number State |
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