Provider Demographics
NPI:1639579568
Name:COMMUNITY EXPERIENCES LLC
Entity Type:Organization
Organization Name:COMMUNITY EXPERIENCES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARREOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-261-8403
Mailing Address - Street 1:11107 LITTLE CREEK LN
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32506-8262
Mailing Address - Country:US
Mailing Address - Phone:850-261-8403
Mailing Address - Fax:850-458-8177
Practice Address - Street 1:321 N DEVILLERS ST SUITE 221
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502
Practice Address - Country:US
Practice Address - Phone:850-261-8403
Practice Address - Fax:850-458-8177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002217700Medicaid
FL686104196Medicaid