1972928455 NPI number — GENOMA HOME HEALTH CARE AGENCY, INC.

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 1972928455 NPI number — GENOMA HOME HEALTH CARE AGENCY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENOMA HOME HEALTH CARE AGENCY, INC.
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:
1972928455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1499 FOREST HILL BLVD
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
LAKE CLARKE SHORES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33406-6050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-410-5622
Provider Business Mailing Address Fax Number:
561-410-5621

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1499 FOREST HILL BLVD
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
LAKE CLARKE SHORES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33406-6050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-410-5622
Provider Business Practice Location Address Fax Number:
561-410-5621
Provider Enumeration Date:
02/20/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MIRANDA
Authorized Official First Name:
RAYDEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
561-410-5622

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: 015650600 . 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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