=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568589372
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERIM HEALTHCARE PRIVATE SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2007
-----------------------------------------------------
Last Update Date | 08/29/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32644 BLOSSOM LN
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34788-3928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-326-0400
-----------------------------------------------------
Fax | 352-365-1521
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32644 BLOSSOM LN
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34788-3928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-326-0400
-----------------------------------------------------
Fax | 352-365-1521
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PRESIDENT
-----------------------------------------------------
Name | EDWARD BIXBY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-326-0400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 20578096
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------