Basic Information
Provider Information | |||||||||
NPI: | 1073747309 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AMEDIHEALTH HOME CARE SERVICES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1527 E MEMORIAL BLVD | ||||||||
Address2: |   | ||||||||
City: | LAKELAND | ||||||||
State: | FL | ||||||||
PostalCode: | 338012222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8636887241 | ||||||||
FaxNumber: | 8639379319 | ||||||||
Practice Location | |||||||||
Address1: | 1527 E MEMORIAL BLVD | ||||||||
Address2: |   | ||||||||
City: | LAKELAND | ||||||||
State: | FL | ||||||||
PostalCode: | 338012222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8636881196 | ||||||||
FaxNumber: | 8636877707 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/14/2009 | ||||||||
LastUpdateDate: | 05/18/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REGIDOR | ||||||||
AuthorizedOfficialFirstName: | JOSEPH | ||||||||
AuthorizedOfficialMiddleName: | V | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 8636887241 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X |   |   | Y |   | Agencies | Home Health |   |
No ID Information.