MEDICARE: CKCTB, 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	251E00000X	Home Health Agency	299992995	FL
2	253Z00000X	In Home Supportive Care Agency	299992995	FL
3	302F00000X	Exclusive Provider Organization	299992995	FL

General Provider Information

NPI Number	:	1790037216
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CKCTB, INC

Provider Business Mailing Address
First Line	:	12493 BRANTLEY COMMONS CT
Second Line	:	SUITE 101
City	:	FORT MYERS
State	:	FL
Zip	:	33907-5693
Country	:	US
Telephone Number	:	239-590-8999
Fax Number	:	239-590-8992

Provider Business Practice Location Address
First Line	:	12493 BRANTLEY COMMONS CT
Second Line	:	SUITE 101
City	:	FORT MYERS
State	:	FL
Zip	:	33907-5693
Country	:	US
Telephone Number	:	239-590-8999
Fax Number	:	239-590-8992

Authorized Official
Title or Position	:	OWNER
Name	:	MR. TOM DEAN
Credential	:
Telephone Number	:	239-590-8999

Provider Enumeration Date	:	10/08/2012
Last Update Date	:	08/21/2013

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