=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073304218
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FM1AFH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2025
-----------------------------------------------------
Last Update Date | 05/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1132 GAMMON LN
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53719-2211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-813-7313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1132 GAMMON LN
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53719-2211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-813-7313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LIBAN MOHAMUD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 614-813-7313
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------