Provider Demographics
NPI:1780175273
Name:ELDER SERVICES OF CENTRAL FLORIDA, INC
Entity type:Organization
Organization Name:ELDER SERVICES OF CENTRAL FLORIDA, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-701-9100
Mailing Address - Street 1:902 S FLORIDA AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-1183
Mailing Address - Country:US
Mailing Address - Phone:863-701-9100
Mailing Address - Fax:863-644-8077
Practice Address - Street 1:17901 HUNTING BOW CIR STE 101
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558
Practice Address - Country:US
Practice Address - Phone:813-920-4440
Practice Address - Fax:863-644-8077
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELDER SERVICES OF CENTRAL FLORIDA, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-21
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL299994676251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000765900Medicaid