=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033713698
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VON ELIJAH HOME HEALTH CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2020
-----------------------------------------------------
Last Update Date | 11/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9718 CANE CREEK DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77070-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-212-4005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9718 CANE CREEK DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77070-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-212-4005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. KEEON RUDDER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-212-4005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------