Provider Demographics
NPI:1992343255
Name:PRISTINE HOMECARE
Entity type:Organization
Organization Name:PRISTINE HOMECARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATEO
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-490-5705
Mailing Address - Street 1:624 EXECUTIVE PARK CT STE 1016A
Mailing Address - Street 2:STE 1016A
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703
Mailing Address - Country:US
Mailing Address - Phone:215-490-5705
Mailing Address - Fax:
Practice Address - Street 1:1320 N SEMORAN BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807
Practice Address - Country:US
Practice Address - Phone:407-955-9483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-18
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113083400Medicaid