MEDICARE: HOME RUN HEALTHCARE

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	207QG0300X	Geriatric Medicine (Family Medicine) Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568957348
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOME RUN HEALTHCARE

Provider Business Mailing Address
First Line	:	PO BOX 51
Second Line	:
City	:	GARVIN
State	:	OK
Zip	:	74736-0051
Country	:	US
Telephone Number	:	580-212-7237
Fax Number	:

Provider Business Practice Location Address
First Line	:	1425 EAST LINCOLN ROAD
Second Line	:	SUITE A-3
City	:	IDABEL
State	:	OK
Zip	:	74745
Country	:	US
Telephone Number	:	580-212-7237
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ASHLEI JOBE
Credential	:	NURSE PRACTIONER
Telephone Number	:	580-212-7237

Provider Enumeration Date	:	06/25/2018
Last Update Date	:	06/25/2018

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Directions to “HOME RUN HEALTHCARE ” Practice Location

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