Provider Demographics
NPI:1932146776
Name:PORT CHARLOTTE HMA LLC
Entity Type:Organization
Organization Name:PORT CHARLOTTE HMA LLC
Other - Org Name:PEACE RIVER HOME HEALTH SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:HOLTSFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7466
Mailing Address - Street 1:15121 TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34287-2711
Mailing Address - Country:US
Mailing Address - Phone:941-423-5183
Mailing Address - Fax:941-423-5184
Practice Address - Street 1:15121 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-2711
Practice Address - Country:US
Practice Address - Phone:941-423-5183
Practice Address - Fax:941-423-5184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH8POtherBLUE CROSS HHA
FLH8POtherBLUE CROSS HHA