Organization
YOUR MEDWAIVER PROVIDER INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ANATOLY N LUKYANOV (CEO)
(352) 474-8492
Entity
Organization
Contact information
Practice address
13200 W NEWBERRY RD, J50, NEWBERRY, FL 32669-2764
(352) 474-8492
Mailing address
13200 W NEWBERRY RD, J50, NEWBERRY, FL 32669-2764
(352) 474-8492
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
—
—
253Z00000X
In Home Supportive Care Agency
Primary
—
—
Other
Enumeration date
10/25/2010
Last updated
10/25/2010
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