Provider Demographics
NPI:1114399821
Name:FULL CIRCLE HOMECARE, LLC
Entity Type:Organization
Organization Name:FULL CIRCLE HOMECARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVANZO
Authorized Official - Middle Name:LAMANAS
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-974-5415
Mailing Address - Street 1:4495 MARKET ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-1573
Mailing Address - Country:US
Mailing Address - Phone:330-974-5415
Mailing Address - Fax:234-719-1476
Practice Address - Street 1:4495 MARKET ST STE 200
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512
Practice Address - Country:US
Practice Address - Phone:330-974-5415
Practice Address - Fax:234-719-1476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-21
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0135706Medicaid