Provider Demographics
NPI:1962888529
Name:AFFINITY HOME CARE AGENCY, INC.
Entity type:Organization
Organization Name:AFFINITY HOME CARE AGENCY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MERLENE
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MASTERS OF EDUCATION
Authorized Official - Phone:850-765-5241
Mailing Address - Street 1:4070 42ND SQUARE
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32967-3902
Mailing Address - Country:US
Mailing Address - Phone:850-345-4806
Mailing Address - Fax:
Practice Address - Street 1:4070 42ND SQUARE
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32967
Practice Address - Country:US
Practice Address - Phone:850-345-4806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AFFINITY HOME CARE AGENCY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-06
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X, 372600000X
FL372600000X376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005820003Medicaid