=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336189166
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALPHA BRIDGE HOME HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2006
-----------------------------------------------------
Last Update Date | 02/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1543 LAKELAND HILLS BLVD SUITE C
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33805-3246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-937-8370
-----------------------------------------------------
Fax | 863-937-8398
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1543 LAKELAND HILLS BLVD SUITE C
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33805-3246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-937-8370
-----------------------------------------------------
Fax | 863-937-8398
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. DELBERT SCOTT WOOD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-397-4101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 299992370
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------