1992343255 NPI number — PRISTINE HOMECARE

Table of content: (NPI 1992343255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992343255 NPI number — PRISTINE HOMECARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRISTINE HOMECARE
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:
Provider Other Organization Name Type Code:
6
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:
1992343255
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
624 EXECUTIVE PARK CT STE 1016A
Provider Second Line Business Mailing Address:
STE 1016A
Provider Business Mailing Address City Name:
APOPKA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-490-5705
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1320 N SEMORAN BLVD
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-955-9483
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/18/2019

Additional Information

Authorized Official

Authorized Official Last Name:
MARTINEZ
Authorized Official First Name:
MATEO
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
215-490-5705

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 113083400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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