MEDICARE: AGAPELIFE HEALTH GROUP, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	1514	FL
2	253Z00000X	In Home Supportive Care Agency	299994085	FL
3	251E00000X	Home Health Agency	299994085	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1514	OTHER	FL	HEALTH CARE SERVICES POOL
2	299994085	OTHER	FL	ACHA HOME HEALTH AGENCY LICENSE
3	232597	OTHER	FL	ACHA HOMEMAKER COMPANION LICENSE
4	10D2043310	OTHER	FL	CLIA WAIVER

General Provider Information

NPI Number	:	1164783494
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGAPELIFE HEALTH GROUP, LLC

Provider Business Mailing Address
First Line	:	3545 SAINT JOHNS BLUFF RD S
Second Line	:	1-214
City	:	JACKSONVILLE
State	:	FL
Zip	:	32224-2682
Country	:	US
Telephone Number	:	904-807-9955
Fax Number	:	904-807-9954

Provider Business Practice Location Address
First Line	:	12187 BEACH BLVD
Second Line	:	SUITE 7
City	:	JACKSONVILLE
State	:	FL
Zip	:	32246-0676
Country	:	US
Telephone Number	:	904-807-9955
Fax Number	:	904-807-9954

Authorized Official
Title or Position	:	OWNER, AGENCY DIRECTOR
Name	:	ANDREA I HART
Credential	:	MPH
Telephone Number	:	904-807-9955

Provider Enumeration Date	:	06/04/2012
Last Update Date	:	03/12/2013

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