=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205640729
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COTTON CANDY CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2025
-----------------------------------------------------
Last Update Date | 02/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4833 MELVILLE AVE STE B
-----------------------------------------------------
City | EAST CHICAGO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46312-3555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-894-3505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3455 PATEVILLE RD
-----------------------------------------------------
City | CORDELE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31015-8747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-894-3505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / ADMINISTRATOR
-----------------------------------------------------
Name | AVA LYNN MURRAY CHAVARRIA
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 229-894-3505
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------