MEDICARE: DESOTO HOME CARE

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	332BX2000X	Oxygen Equipment & Supplies (DME)	1919	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R9451	OTHER	FL	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1235132671
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESOTO HOME CARE

Provider Business Mailing Address
First Line	:	311 N MARION AVE
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32055-2866
Country	:	US
Telephone Number	:	386-752-1699
Fax Number	:	386-752-6000

Provider Business Practice Location Address
First Line	:	311 N MARION AVE
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32055-2866
Country	:	US
Telephone Number	:	386-752-1699
Fax Number	:	386-752-6000

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. SHAUN GRUBB
Credential	:
Telephone Number	:	386-752-1699

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	08/22/2020

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Directions to “DESOTO HOME CARE ” Practice Location

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