=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528315355
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGING CONCEPTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2012
-----------------------------------------------------
Last Update Date | 08/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3759 BLUE CROWN LN
-----------------------------------------------------
City | EUSTIS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32736-2249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-579-0426
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3759 BLUE CROWN LN
-----------------------------------------------------
City | EUSTIS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32736-2249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-579-0426
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. TONYA OLIVER
-----------------------------------------------------
Credential | MA, LNHA
-----------------------------------------------------
Telephone | 407-579-0326
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 232733
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 232733
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------