Provider Demographics
NPI:1891947461
Name:BIG LAKE HOME HEALTH SERVICES OF GLADE COUNTY, INC
Entity type:Organization
Organization Name:BIG LAKE HOME HEALTH SERVICES OF GLADE COUNTY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHAHNAZ
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-763-0804
Mailing Address - Street 1:#7 BUCKHEAD RIDGE ROAD
Mailing Address - Street 2:BUCKHEAD RIDGE
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34974
Mailing Address - Country:US
Mailing Address - Phone:863-763-0804
Mailing Address - Fax:863-763-0132
Practice Address - Street 1:#7 BUCKHEAD RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34974
Practice Address - Country:US
Practice Address - Phone:863-763-0804
Practice Address - Fax:863-763-0132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL299992606251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAX ID