Provider Demographics
NPI:1548638216
Name:ATLANTIC IN-HOME CARE, LLC
Entity type:Organization
Organization Name:ATLANTIC IN-HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-462-6707
Mailing Address - Street 1:240 NW PEACOCK BLVD STE 304
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2274
Mailing Address - Country:US
Mailing Address - Phone:772-462-6707
Mailing Address - Fax:772-463-6706
Practice Address - Street 1:240 NW PEACOCK BLVD STE 304
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2274
Practice Address - Country:US
Practice Address - Phone:772-462-6707
Practice Address - Fax:772-462-6706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-10
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X, 251E00000X, 251J00000X
FLNR30211036253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016181800Medicaid