Provider Demographics
NPI:1902559289
Name:ILEANA'S CARE HOME INC
Entity Type:Organization
Organization Name:ILEANA'S CARE HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ILEANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERMUDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-741-5460
Mailing Address - Street 1:6401 W CLIFTON ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-5010
Mailing Address - Country:US
Mailing Address - Phone:201-741-5460
Mailing Address - Fax:813-559-7301
Practice Address - Street 1:6401 W CLIFTON ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-5010
Practice Address - Country:US
Practice Address - Phone:201-741-5460
Practice Address - Fax:813-559-7301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022857600Medicaid