Provider Demographics
NPI:1629712013
Name:C AND C SHELTER CARE LLC
Entity Type:Organization
Organization Name:C AND C SHELTER CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLLETTE
Authorized Official - Middle Name:KATRELL
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-673-7212
Mailing Address - Street 1:7414 IRVING SCOTT DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-1029
Mailing Address - Country:US
Mailing Address - Phone:904-673-7212
Mailing Address - Fax:904-212-0253
Practice Address - Street 1:2268 PLACEDA ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6968
Practice Address - Country:US
Practice Address - Phone:904-673-7212
Practice Address - Fax:904-212-0253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015058700Medicaid