=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275954497
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGELIKA'S COUNTRYSIDE ADULT CARE HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2013
-----------------------------------------------------
Last Update Date | 12/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12102 CROMWELL WAY
-----------------------------------------------------
City | SPRING HILL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34609-9640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-610-0121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12102 CROMWELL WAY
-----------------------------------------------------
City | SPRING HILL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34609-9640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-610-0121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANGELIKA E GIECK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-610-0121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 6906571
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------