=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568807857
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAVECARE HEALTH SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2013
-----------------------------------------------------
Last Update Date | 05/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1353 OAKFIELD DR
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511-4823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-237-1141
-----------------------------------------------------
Fax | 202-388-9558
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1353 OAKFIELD DR
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511-4823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-699-3405
-----------------------------------------------------
Fax | 813-699-3406
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT
-----------------------------------------------------
Name | MRS. WAVENEY ALBERTHA BLACKMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-237-1141
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BP3500X
-----------------------------------------------------
Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BX2000X
-----------------------------------------------------
Taxonomy Name | Oxygen Equipment & Supplies (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------