Provider Demographics
NPI:1487821807
Name:HEART OF FLORIDA CARE INC.
Entity type:Organization
Organization Name:HEART OF FLORIDA CARE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LALLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-421-2982
Mailing Address - Street 1:301 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-5601
Mailing Address - Country:US
Mailing Address - Phone:863-421-2982
Mailing Address - Fax:
Practice Address - Street 1:301 S 10TH ST
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-5601
Practice Address - Country:US
Practice Address - Phone:863-421-2982
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9965261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11194301OtherMEDICAID DIVERSION PROVIDER #
FL284871OtherDIVERSION PROVIDER #
FL6000793OtherMEDICAID DIVERSION PROVIDER #
FL683660700Medicaid
FL140884400Medicaid