Provider Demographics
NPI:1164866711
Name:SEMINOLE SUPPORT SERVICES
Entity Type:Organization
Organization Name:SEMINOLE SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:ROBIN
Authorized Official - Last Name:STALLWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-328-9976
Mailing Address - Street 1:504 S SANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-1973
Mailing Address - Country:US
Mailing Address - Phone:407-328-9976
Mailing Address - Fax:407-328-0195
Practice Address - Street 1:504 S SANFORD AVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1973
Practice Address - Country:US
Practice Address - Phone:407-328-9976
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL229055251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003951900Medicaid