Healthcare Provider Details

I. General information

NPI: 1003091646
Provider Name (Legal Business Name): HEPHZIBAH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2008
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 MISTY MESA TRL
MANSFIELD TX
76063-4817
US

IV. Provider business mailing address

201 MISTY MESA TRL
MANSFIELD TX
76063-4817
US

V. Phone/Fax

Practice location:
  • Phone: 817-453-5506
  • Fax:
Mailing address:
  • Phone: 817-453-5506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MRS. BOLADE OLUSOLA ADE-JAGUN
Title or Position: ADMINISTRATOR
Credential:
Phone: 817-453-5506