MEDICARE: SHANEDAS TIME TO CARE 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	261QD1600X	Developmental Disabilities Clinic/Center
2	261QD1600X	Developmental Disabilities Clinic/Center		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

General Provider Information

NPI Number	:	1336651207
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHANEDAS TIME TO CARE LLC

Provider Business Mailing Address
First Line	:	1881 SW ELIJAH AVE
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-3495
Country	:	US
Telephone Number	:	772-501-6619
Fax Number	:

Provider Business Practice Location Address
First Line	:	6233 NW GISELA ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34986-3866
Country	:	US
Telephone Number	:	772-777-9827
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. SHANEADA VANCOL I
Credential	:
Telephone Number	:	772-501-6619

Provider Enumeration Date	:	10/31/2017
Last Update Date	:	07/12/2024

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Directions to “SHANEDAS TIME TO CARE LLC ” Practice Location

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