MEDICARE: TIME OUT RESPITE CARE, INC.

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	251C00000X	Developmentally Disabled Services Day Training Agency	089079	FL
2	253Z00000X	In Home Supportive Care Agency	089079	FL
3	385HR2065X	Child Physical Disabilities Respite Care	089079	FL
4	343900000X	Non-emergency Medical Transport (VAN)	089079	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265735179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIME OUT RESPITE CARE, INC.

Provider Business Mailing Address
First Line	:	24246 HARBORVIEW RD
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33980-2232
Country	:	US
Telephone Number	:	941-743-3883
Fax Number	:	941-743-4369

Provider Business Practice Location Address
First Line	:	24246 HARBORVIEW RD
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33980-2232
Country	:	US
Telephone Number	:	941-743-3883
Fax Number	:	941-743-4369

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. SHARON CHRISTINA HARTZELL
Credential	:
Telephone Number	:	941-743-3883

Provider Enumeration Date	:	12/15/2010
Last Update Date	:	12/15/2010

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Directions to “TIME OUT RESPITE CARE, INC. ” Practice Location

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