Provider Demographics
NPI:1326572272
Name:JUDAH IN HOME SUPPORT CARE INC
Entity type:Organization
Organization Name:JUDAH IN HOME SUPPORT CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARMAINE
Authorized Official - Middle Name:GAYNOR
Authorized Official - Last Name:MUIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-203-4762
Mailing Address - Street 1:4812 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-7078
Mailing Address - Country:US
Mailing Address - Phone:772-203-4762
Mailing Address - Fax:
Practice Address - Street 1:4812 S FEDERAL HWY # 1
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-7078
Practice Address - Country:US
Practice Address - Phone:772-742-8145
Practice Address - Fax:772-742-8145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL017020700251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018713800Medicaid
FL017020700Medicaid