MEDICARE: FROM THE HEART MEDWAIVER PROVIDER, 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	251C00000X	Developmentally Disabled Services Day Training Agency		FL

General Provider Information

NPI Number	:	1891702676
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FROM THE HEART MEDWAIVER PROVIDER, INC

Provider Business Mailing Address
First Line	:	3001 PERCY RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-2325
Country	:	US
Telephone Number	:	904-764-3127
Fax Number	:	904-764-2659

Provider Business Practice Location Address
First Line	:	3001 PERCY RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-2325
Country	:	US
Telephone Number	:	904-764-3127
Fax Number	:	904-764-2659

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. CHARLOTTE JEAN CARUSO
Credential	:
Telephone Number	:	904-764-3127

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	06/05/2008

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