=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043928633
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXCEL IN CARE HOME HEALTH AGENCY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2022
-----------------------------------------------------
Last Update Date | 11/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 819 WALNUT PARK DR
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23434-4159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-725-1018
-----------------------------------------------------
Fax | 757-970-0909
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 819 WALNUT PARK DR
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23434-4159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-725-1018
-----------------------------------------------------
Fax | 757-970-0909
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | SHANNON MARKETA GRAY
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 757-725-1018
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------