Provider Demographics
NPI:1164783494
Name:AGAPELIFE HEALTH GROUP, LLC
Entity Type:Organization
Organization Name:AGAPELIFE HEALTH GROUP, LLC
Other - Org Name:BRIGHTSTAR CARE OF THE BEACHES & PONTE VEDRA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, AGENCY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:I
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:904-807-9955
Mailing Address - Street 1:3545 SAINT JOHNS BLUFF RD S
Mailing Address - Street 2:1-214
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-2682
Mailing Address - Country:US
Mailing Address - Phone:904-807-9955
Mailing Address - Fax:904-807-9954
Practice Address - Street 1:12187 BEACH BLVD
Practice Address - Street 2:SUITE 7
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-0676
Practice Address - Country:US
Practice Address - Phone:904-807-9955
Practice Address - Fax:904-807-9954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-04
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1514251E00000X
FL299994085251E00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1514OtherHEALTH CARE SERVICES POOL
FL299994085OtherACHA HOME HEALTH AGENCY LICENSE
FL232597OtherACHA HOMEMAKER COMPANION LICENSE
FL10D2043310OtherCLIA WAIVER