Provider Demographics
NPI:1235132671
Name:DESOTO HOME CARE
Entity Type:Organization
Organization Name:DESOTO HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-752-1699
Mailing Address - Street 1:311 N MARION AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-2866
Mailing Address - Country:US
Mailing Address - Phone:386-752-1699
Mailing Address - Fax:386-752-6000
Practice Address - Street 1:311 N MARION AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-2866
Practice Address - Country:US
Practice Address - Phone:386-752-1699
Practice Address - Fax:386-752-6000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1919332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLR9451OtherBCBS PROVIDER NUMBER
FLR9451OtherBCBS PROVIDER NUMBER