Provider Demographics
NPI:1629582663
Name:MY RESIDENCE CARE PLACE LLC
Entity Type:Organization
Organization Name:MY RESIDENCE CARE PLACE LLC
Other - Org Name:MY RESIDENCE CARE PLAC LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:RICHELLE
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-484-5495
Mailing Address - Street 1:10175 COUNTY ROAD 229
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:FL
Mailing Address - Zip Code:34484-3955
Mailing Address - Country:US
Mailing Address - Phone:352-484-5495
Mailing Address - Fax:352-330-0621
Practice Address - Street 1:10175 COUNTY ROAD 229
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:FL
Practice Address - Zip Code:34484-3955
Practice Address - Country:US
Practice Address - Phone:352-484-5495
Practice Address - Fax:352-330-0621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-29
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL234865251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017159100Medicaid