Basic Information
| Provider Information | |||||||||
| NPI: | 1033157854 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUNTA GORDA HMA LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | HOME HEALTH SVCS OF CHARLOTTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 809 E MARION AVE | ||||||||
| Address2: | |||||||||
| City: | PUNTA GORDA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339503819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416393131 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 809 E MARION AVE | ||||||||
| Address2: | |||||||||
| City: | PUNTA GORDA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339503819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416393131 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 07/28/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PARRY | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR VP AND GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 2395983176 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | ESQ | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | J80 | 01 | FL | BLUE CROSS | OTHER | 650449300 | 05 | FL | MEDICAID |