Healthcare Provider Details

I. General information

NPI: 1558800490
Provider Name (Legal Business Name): RADIANT HOME CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 02/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S CLARK ST
GALLUP NM
87301-6678
US

IV. Provider business mailing address

13236 W ANNIKA DR
LITCHFIELD PARK AZ
85340-8363
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-9951
  • Fax: 505-722-9952
Mailing address:
  • Phone: 505-722-9951
  • Fax: 505-722-9952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. JULIANA OFOSUA BONNEY
Title or Position: AGENCY DIRECTOR
Credential:
Phone: 505-879-1587