=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063222594
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIBELL HOME HEALTH CARE AGENCY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2025
-----------------------------------------------------
Last Update Date | 01/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28986 SUGAR ISLAND CT
-----------------------------------------------------
City | GIBRALTAR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48173-9578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-929-4645
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28986 SUGAR ISLAND CT
-----------------------------------------------------
City | GIBRALTAR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48173-9578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-929-4645
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRITTIANEE PETTAWAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-929-4645
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------