Provider Demographics
NPI:1336647940
Name:NICHOLAS CUMMINGS DBA QUALITY CARE LIVING PHASE I
Entity Type:Organization
Organization Name:NICHOLAS CUMMINGS DBA QUALITY CARE LIVING PHASE I
Other - Org Name:QUALITY CARE LIVING PHASE I
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:CUMMINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-504-7479
Mailing Address - Street 1:1805 N ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-3013
Mailing Address - Country:US
Mailing Address - Phone:352-504-7479
Mailing Address - Fax:352-735-1904
Practice Address - Street 1:1805 N ORANGE ST
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-3013
Practice Address - Country:US
Practice Address - Phone:352-504-7479
Practice Address - Fax:352-735-1904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018025200Medicaid