Healthcare Provider Details

I. General information

NPI: 1578259594
Provider Name (Legal Business Name): HERMITAGE HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 14TH PL
PLANO TX
75074-6403
US

IV. Provider business mailing address

1705 14TH PL
PLANO TX
75074-6403
US

V. Phone/Fax

Practice location:
  • Phone: 214-551-6470
  • Fax:
Mailing address:
  • Phone: 214-551-6470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: AUDREY ELAINE DAVIS
Title or Position: OWNER
Credential: RN
Phone: 214-551-6470