=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912538646
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAITH IN HOME PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2020
-----------------------------------------------------
Last Update Date | 02/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2401 FOREST DR
-----------------------------------------------------
City | INVERNESS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34453-3720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-344-3777
-----------------------------------------------------
Fax | 352-344-2546
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2401 FOREST DR
-----------------------------------------------------
City | INVERNESS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34453-3720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-344-3777
-----------------------------------------------------
Fax | 352-344-2546
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AMBR
-----------------------------------------------------
Name | JOSHUA SUMMERS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 352-344-3777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------