Provider Demographics
NPI: | 1952951733 |
---|---|
Name: | JESSICADAVISCEO, LLC |
Entity Type: | Organization |
Organization Name: | JESSICADAVISCEO, LLC |
Other - Org Name: | PASSIONATE CHAMPION |
Other - Org Type: | Former Legal Business Name |
Authorized Official - Title/Position: | ADMINISTRATOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JESSICA |
Authorized Official - Middle Name: | ALEXANDRA |
Authorized Official - Last Name: | DAVIS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 321-877-0328 |
Mailing Address - Street 1: | 2550 PALM BAY RD NE STE 106 |
Mailing Address - Street 2: | |
Mailing Address - City: | PALM BAY |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32905-3565 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 321-877-0328 |
Mailing Address - Fax: | 321-978-0288 |
Practice Address - Street 1: | 307 N GEORGIA AVE |
Practice Address - Street 2: | |
Practice Address - City: | COCOA |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32922-6222 |
Practice Address - Country: | US |
Practice Address - Phone: | 321-557-8979 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2019-09-13 |
Last Update Date: | 2020-10-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251E00000X | Agencies | Home Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 1952951733 | Other | N/A |