=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043640360
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILLENNIUM HOME HEALTH CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2013
-----------------------------------------------------
Last Update Date | 09/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4810 BEAUREGARD ST SUITE 325
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22312-1709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-941-8412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4810 BEAUREGARD ST SUITE 325
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22312-1709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-941-8412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. MULUEMBET FISSEHA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-862-8447
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HCO-14982
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------