Provider Demographics
NPI:1497055487
Name:YOUR MEDWAIVER PROVIDER INC
Entity Type:Organization
Organization Name:YOUR MEDWAIVER PROVIDER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANATOLY
Authorized Official - Middle Name:N
Authorized Official - Last Name:LUKYANOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-474-8492
Mailing Address - Street 1:13200 W NEWBERRY RD
Mailing Address - Street 2:J50
Mailing Address - City:NEWBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32669-2764
Mailing Address - Country:US
Mailing Address - Phone:352-474-8492
Mailing Address - Fax:
Practice Address - Street 1:13200 W NEWBERRY RD
Practice Address - Street 2:J50
Practice Address - City:NEWBERRY
Practice Address - State:FL
Practice Address - Zip Code:32669-2764
Practice Address - Country:US
Practice Address - Phone:352-474-8492
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251B00000XAgenciesCase Management