Provider Demographics
NPI:1073544698
Name:HOMETOWN HOMECARE LLC
Entity Type:Organization
Organization Name:HOMETOWN HOMECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:O
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-401-3550
Mailing Address - Street 1:250 MAGNOLIA AVE SW
Mailing Address - Street 2:STE 300
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-2901
Mailing Address - Country:US
Mailing Address - Phone:863-401-3550
Mailing Address - Fax:863-401-8199
Practice Address - Street 1:350 MAGNOLIA AVE SW
Practice Address - Street 2:300
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880
Practice Address - Country:US
Practice Address - Phone:863-401-3550
Practice Address - Fax:863-401-8199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
299991974251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
108103Medicare ID - Type Unspecified