MEDICARE: LATRELL'S HEAVENLY HOME CARE

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	343900000X	Non-emergency Medical Transport (VAN)
2	385H00000X	Respite Care
3	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1386313419
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LATRELL'S HEAVENLY HOME CARE

Provider Business Mailing Address
First Line	:	3664 BRENTWOOD BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-1869
Country	:	US
Telephone Number	:	904-731-6109
Fax Number	:	904-250-5902

Provider Business Practice Location Address
First Line	:	3664 BRENTWOOD BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-1869
Country	:	US
Telephone Number	:	904-731-6109
Fax Number	:	904-250-5902

Authorized Official
Title or Position	:	OWNER
Name	:	LATRELL DELORES GASKIN
Credential	:
Telephone Number	:	904-731-6109

Provider Enumeration Date	:	09/11/2021
Last Update Date	:	09/11/2021

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