Healthcare Provider Details

I. General information

NPI: 1609129766
Provider Name (Legal Business Name): ELIJAH-YESHUA HOME HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2012
Last Update Date: 03/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10225 CANDLEWYCK ST
FORT WORTH TX
76244-5038
US

IV. Provider business mailing address

10225 CANDLEWYCK ST
FORT WORTH TX
76244-5038
US

V. Phone/Fax

Practice location:
  • Phone: 817-562-2615
  • Fax:
Mailing address:
  • Phone: 817-562-2615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. EDITH L ODIWO
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 817-562-2615