Provider Demographics
NPI:1750684809
Name:HOME AGAIN OF SOUTHWEST FLORIDA,INC.
Entity type:Organization
Organization Name:HOME AGAIN OF SOUTHWEST FLORIDA,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-743-4857
Mailing Address - Street 1:PO BOX 380183
Mailing Address - Street 2:
Mailing Address - City:MURDOCK
Mailing Address - State:FL
Mailing Address - Zip Code:33938-0183
Mailing Address - Country:US
Mailing Address - Phone:941-743-4857
Mailing Address - Fax:800-921-4989
Practice Address - Street 1:1357 RAMSDEL ST
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-2887
Practice Address - Country:US
Practice Address - Phone:941-743-4857
Practice Address - Fax:800-921-4989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251S00000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
678473996OtherMEDICAID WAIVER