=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477042620
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CDS CARE & SUPPORT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2018
-----------------------------------------------------
Last Update Date | 11/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2726 OAK RIDGE CT STE 502
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33901-9356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-931-0158
-----------------------------------------------------
Fax | 850-757-0070
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2726 OAK RIDGE CT STE 502
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33901-9356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-931-0158
-----------------------------------------------------
Fax | 850-757-0070
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. MANUEL CHAVEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 239-931-0262
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 299994703
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------