=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083756720
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIRASOL PRIMARY HOME CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2007
-----------------------------------------------------
Last Update Date | 05/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 710 E GRIFFIN PKWY SUITE C
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-581-1351
-----------------------------------------------------
Fax | 956-581-2306
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 710 E GRIFFIN PKWY SUITE C
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78572-2910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-581-1351
-----------------------------------------------------
Fax | 956-581-2306
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. YOLANDA BALDERAS
-----------------------------------------------------
Credential | R.N.
-----------------------------------------------------
Telephone | 956-581-1351
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 006581
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------