1508465725 NPI number — MAHANAIM HOME CARE L.L.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508465725 NPI number — MAHANAIM HOME CARE L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAHANAIM HOME CARE L.L.C.
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:
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:
1508465725
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2750 N 29 AVENUE SUITE 218B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLYWOOD FL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33020-3982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-270-0563
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2750 N 29TH AVE STE 218B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33020-1521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-270-0563
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/19/2020

Additional Information

Authorized Official

Authorized Official Last Name:
FRAZIL
Authorized Official First Name:
MYRIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
954-270-0562

Provider Taxonomy Codes

  • Taxonomy code: 163WH0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 113524100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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