MEDICARE: HOUSE OF WELLNESS FAMILY HOME CARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251C00000X	Developmentally Disabled Services Day Training Agency
2	253Z00000X	In Home Supportive Care Agency
3	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1073345054
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOUSE OF WELLNESS FAMILY HOME CARE, LLC

Provider Business Mailing Address
First Line	:	791 GLENDALE LN
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32065-5628
Country	:	US
Telephone Number	:	904-328-4485
Fax Number	:

Provider Business Practice Location Address
First Line	:	791 GLENDALE LN
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32065-5628
Country	:	US
Telephone Number	:	904-328-4485
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KETTLY JEAN LOUIS
Credential	:	ADMINISTRATOR
Telephone Number	:	904-328-4485

Provider Enumeration Date	:	08/17/2024
Last Update Date	:	08/17/2024

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