Healthcare Provider Details

I. General information

NPI: 1083101075
Provider Name (Legal Business Name): HEPHZIBAH VISITING CLINICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 EXECUTIVE WAY STE 102
DESOTO TX
75115-2388
US

IV. Provider business mailing address

7268 PORTILLO
GRAND PRAIRIE TX
75054-0073
US

V. Phone/Fax

Practice location:
  • Phone: 469-941-4029
  • Fax: 866-803-8759
Mailing address:
  • Phone: 469-585-8129
  • Fax: 866-803-8759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SIMINIBE MONEKE
Title or Position: MANAGING MEMBER
Credential:
Phone: 469-585-8129