MEDICARE: CHARLES B FARMER II LPN

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	253Z00000X	In Home Supportive Care Agency	LPN0000040736	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LPN0000040736	OTHER	TN	STATE ISSUED

General Provider Information

NPI Number	:	1992434377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES B FARMER II LPN

Provider Business Mailing Address
First Line	:	418 E CHURCH AVE # 55
Second Line	:
City	:	MEDINA
State	:	TN
Zip	:	38355-9762
Country	:	US
Telephone Number	:	731-267-6861
Fax Number	:

Provider Business Practice Location Address
First Line	:	3939 EASTGATE CT
Second Line	:
City	:	NORTH FORT MYERS
State	:	FL
Zip	:	33917-7236
Country	:	US
Telephone Number	:	239-543-6099
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2022
Last Update Date	:	06/09/2022

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