=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104191915
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DECHMAN LEGACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2012
-----------------------------------------------------
Last Update Date | 02/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9028 STATE HIGHWAY 304
-----------------------------------------------------
City | HARWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78632-4711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-672-6900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9028 STATE HIGHWAY 304
-----------------------------------------------------
City | HARWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78632-4711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-672-6900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DIRECTOR
-----------------------------------------------------
Name | JIMMIE LEE RIVERKAMP
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 830-672-6900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 013984
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------