Provider Demographics
NPI:1386970846
Name:INDIVIDUALIZED SUPPORT SERVICES LLC
Entity type:Organization
Organization Name:INDIVIDUALIZED SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ONER
Authorized Official - Prefix:
Authorized Official - First Name:RENA
Authorized Official - Middle Name:ARLENE
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-696-3189
Mailing Address - Street 1:234 SW STARFLOWER AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-4461
Mailing Address - Country:US
Mailing Address - Phone:772-696-3189
Mailing Address - Fax:772-492-9147
Practice Address - Street 1:1965 42ND AVE STE 3
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-2502
Practice Address - Country:US
Practice Address - Phone:772-492-9159
Practice Address - Fax:772-492-9147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL001173600251E00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001173600OtherPROVIDER NUMBER (HCBS) AND (FSL)