Provider Demographics
NPI:1114355880
Name:PROFESSIONAL CARE SERVICES BY MMLG
Entity Type:Organization
Organization Name:PROFESSIONAL CARE SERVICES BY MMLG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETTIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-502-0236
Mailing Address - Street 1:1026 VICTORY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32221-1388
Mailing Address - Country:US
Mailing Address - Phone:904-502-0236
Mailing Address - Fax:
Practice Address - Street 1:1026 VICTORY LAKE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221-1388
Practice Address - Country:US
Practice Address - Phone:904-502-0236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL675696496Medicaid