Provider Demographics
NPI:1417629742
Name:PROCARE4LIFE
Entity Type:Organization
Organization Name:PROCARE4LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:B
Authorized Official - Last Name:COGHIEL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:813-458-5371
Mailing Address - Street 1:121 VILLAVISTA CT
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33896-8638
Mailing Address - Country:US
Mailing Address - Phone:813-458-5371
Mailing Address - Fax:888-522-0011
Practice Address - Street 1:121 VILLAVISTA CT
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33896-8638
Practice Address - Country:US
Practice Address - Phone:813-458-5371
Practice Address - Fax:888-522-0011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No251J00000XAgenciesNursing Care