Provider Demographics
NPI:1205479342
Name:TIFFANY'S HOMEMAKER AND COMPANION
Entity type:Organization
Organization Name:TIFFANY'S HOMEMAKER AND COMPANION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-450-1430
Mailing Address - Street 1:11039 COLONIAL TAVERN LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32221-2123
Mailing Address - Country:US
Mailing Address - Phone:904-450-1430
Mailing Address - Fax:
Practice Address - Street 1:11039 COLONIAL TAVERN LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221-2123
Practice Address - Country:US
Practice Address - Phone:904-450-1430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-22
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
No251G00000XAgenciesHospice Care, Community Based
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021497100Medicaid