MEDICARE: CRAB BABY 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	174200000X	Meals Provider
2	332U00000X	Home Delivered Meals

General Provider Information

NPI Number	:	1891561221
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRAB BABY LLC

Provider Business Mailing Address
First Line	:	4203 CABELL DR APT 331
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75204-3685
Country	:	US
Telephone Number	:	469-431-0120
Fax Number	:

Provider Business Practice Location Address
First Line	:	3518 SPRING AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75210-2046
Country	:	US
Telephone Number	:	469-431-0120
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ZONADA FULLER
Credential	:
Telephone Number	:	469-431-0120

Provider Enumeration Date	:	11/27/2023
Last Update Date	:	11/27/2023

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