1457380172 NPI number — MID-SOUTH HOME HEALTH AGENCY, LLC

Table of content: (NPI 1457380172)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457380172 NPI number — MID-SOUTH HOME HEALTH AGENCY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-SOUTH HOME HEALTH AGENCY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457380172
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6330 SPRINT PKWY STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OVERLAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66211-1157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1204 W MAGNOLIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GENEVA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36340-1610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-684-3919
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NICHOLS
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED SIGNATORY
Authorized Official Telephone Number:
334-684-3919

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 51512795 . This is a "G2" identifier . This identifiers is of the category "OTHER".
  • Identifier: 51512791 . This is a "G2" identifier . This identifiers is of the category "OTHER".
  • Identifier: 51512793 . This is a "G2" identifier . This identifiers is of the category "OTHER".
  • Identifier: 51512797 . This is a "G2" identifier . This identifiers is of the category "OTHER".
  • Identifier: HOM7048A , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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