Provider Demographics
NPI:1730699893
Name:SIMON COMPANION AND HOMEMAKING
Entity type:Organization
Organization Name:SIMON COMPANION AND HOMEMAKING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:LATRALL
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-508-2687
Mailing Address - Street 1:12458 CONDOR DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-3711
Mailing Address - Country:US
Mailing Address - Phone:904-508-2687
Mailing Address - Fax:904-374-5457
Practice Address - Street 1:12458 CONDOR DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-3711
Practice Address - Country:US
Practice Address - Phone:904-508-2687
Practice Address - Fax:904-374-5457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL020088900251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001477397Medicaid