=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497076889
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILLENNIUM HOUSE OF SOUTHWEST FLORIDA, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2010
-----------------------------------------------------
Last Update Date | 06/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8951 BONITA BEACH RD SE SUITE 297
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34135-4201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-992-5513
-----------------------------------------------------
Fax | 239-992-2238
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8951 BONITA BEACH RD SE SUITE 297
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34135-4201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-992-5513
-----------------------------------------------------
Fax | 239-992-2238
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR/OWNER
-----------------------------------------------------
Name | CYNTHIA KAY RYERSON
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 239-992-5513
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number | AD8985
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------