MEDICARE: CHOICES RESIDENTIAL GROUP 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	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1609363613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHOICES RESIDENTIAL GROUP CARE INC.

Provider Business Mailing Address
First Line	:	5224 W STATE ROAD 46 # 325
Second Line	:
City	:	SANFORD
State	:	FL
Zip	:	32771-9230
Country	:	US
Telephone Number	:	386-259-4985
Fax Number	:	888-558-2226

Provider Business Practice Location Address
First Line	:	667 DELTONA BLVD STE 101
Second Line	:
City	:	DELTONA
State	:	FL
Zip	:	32725-8151
Country	:	US
Telephone Number	:	386-259-4985
Fax Number	:	888-558-2226

Authorized Official
Title or Position	:	CLINICAL SERVICES DIRECTOR
Name	:	MR. SHANNON L THOMAS SR.
Credential	:
Telephone Number	:	386-259-4985

Provider Enumeration Date	:	04/16/2018
Last Update Date	:	04/16/2018

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