1336651207 NPI number — SHANEDAS TIME TO CARE LLC

Table of content: (NPI 1336651207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336651207 NPI number — SHANEDAS TIME TO CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHANEDAS TIME TO CARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHANEADA VANCOL
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336651207
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6233 NW GISELA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT SAINT LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34986-3866
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-307-0705
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6233 NW GISELA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT SAINT LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34986-3866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-777-9827
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VANCOL
Authorized Official First Name:
SHANEADA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
772-307-0705

Provider Taxonomy Codes

  • Taxonomy code: 261QD1600X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QD1600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 022855600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".