Provider Demographics
NPI:1457720815
Name:CUSTOM CARE LLC
Entity Type:Organization
Organization Name:CUSTOM CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:WARTHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-403-8108
Mailing Address - Street 1:291 PLUMTREE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-6155
Mailing Address - Country:US
Mailing Address - Phone:352-403-8108
Mailing Address - Fax:
Practice Address - Street 1:6177 IVY HILL LN
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34602-7925
Practice Address - Country:US
Practice Address - Phone:352-403-8108
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906706310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility