Provider Demographics
NPI:1639335524
Name:AUTUMN HOME CARE OF SOUTH WESTERN FLORIDA, LLC
Entity Type:Organization
Organization Name:AUTUMN HOME CARE OF SOUTH WESTERN FLORIDA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBROSE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:727-398-4467
Mailing Address - Street 1:10773 70TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-6302
Mailing Address - Country:US
Mailing Address - Phone:727-398-4467
Mailing Address - Fax:727-399-9788
Practice Address - Street 1:4456 TAMIAMI TRL
Practice Address - Street 2:SUITE A4
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33980-2101
Practice Address - Country:US
Practice Address - Phone:941-979-5184
Practice Address - Fax:941-979-5237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL299993223251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109501Medicare Oscar/Certification