Provider Demographics
NPI:1336651207
Name:SHANEDAS TIME TO CARE LLC
Entity Type:Organization
Organization Name:SHANEDAS TIME TO CARE LLC
Other - Org Name:SHANEADA VANCOL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANEADA
Authorized Official - Middle Name:
Authorized Official - Last Name:VANCOL
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:772-307-0705
Mailing Address - Street 1:6233 NW GISELA ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3866
Mailing Address - Country:US
Mailing Address - Phone:772-307-0705
Mailing Address - Fax:
Practice Address - Street 1:6233 NW GISELA ST
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-3866
Practice Address - Country:US
Practice Address - Phone:772-777-9827
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-31
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QD1600X
261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022855600Medicaid