MEDICARE: OPTIMUM IN-HOME AIDE AGENCY LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251E00000X	Home Health Agency
2	385H00000X	Respite Care
3	385HR2065X	Child Physical Disabilities Respite Care
4	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1396468831
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMUM IN-HOME AIDE AGENCY LLC

Provider Business Mailing Address
First Line	:	420 79TH TER N APT 211
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33702-4371
Country	:	US
Telephone Number	:	414-704-9031
Fax Number	:

Provider Business Practice Location Address
First Line	:	3801 PARK ST N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33709-4078
Country	:	US
Telephone Number	:	414-704-9031
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JOHNNA SCOTT
Credential	:
Telephone Number	:	414-704-9031

Provider Enumeration Date	:	09/20/2022
Last Update Date	:	09/20/2022

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