MEDICARE: TIDA EXCELLENT HOME CARE JOURNEY 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	261QD1600X	Developmental Disabilities Clinic/Center

General Provider Information

NPI Number	:	1861069494
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDA EXCELLENT HOME CARE JOURNEY INC

Provider Business Mailing Address
First Line	:	9818 ARBOR OAKS LN APT 101
Second Line	:
City	:	BOCA RATON
State	:	FL
Zip	:	33428-2241
Country	:	US
Telephone Number	:	860-908-3593
Fax Number	:

Provider Business Practice Location Address
First Line	:	9818 ARBOR OAKS LN APT 101
Second Line	:
City	:	BOCA RATON
State	:	FL
Zip	:	33428-2241
Country	:	US
Telephone Number	:	860-908-3593
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. STEPHANIE JEANTY
Credential	:
Telephone Number	:	860-908-3593

Provider Enumeration Date	:	06/10/2021
Last Update Date	:	06/10/2021

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