MEDICARE: SHINING HEART'S HOME HEALTH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency		TX

General Provider Information

NPI Number	:	1548665268
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHINING HEART'S HOME HEALTH, LLC

Provider Business Mailing Address
First Line	:	5504 BRENTWOOD STAIR RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-2917
Country	:	US
Telephone Number	:	817-230-9066
Fax Number	:	817-496-9749

Provider Business Practice Location Address
First Line	:	5504 BRENTWOOD STAIR RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-2917
Country	:	US
Telephone Number	:	817-230-9066
Fax Number	:	817-496-9749

Authorized Official
Title or Position	:	OWNER
Name	:	DAIZIA B STERLING
Credential	:
Telephone Number	:	817-230-9066

Provider Enumeration Date	:	10/23/2014
Last Update Date	:	10/23/2014

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