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General NPI Number Information
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NPI Number | 1114259108
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Entity Type | Organization
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Legal Business Name | MIDLAND MODESTY HOME HEALTHCARE
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Dates
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Enumeration Date | 02/02/2010
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Last Update Date | 04/12/2012
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Provider Practice Location Address
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Address Line | 2416 LAKEWOOD DR
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City | PAPILLION
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State | NE
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Zip | 68046-8082
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Country | US
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Telephone | 402-932-3643
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Fax | 402-932-3642
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Provider Business Mailing Address
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Address Line | 2416 LAKEWOOD DR
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City | PAPILLION
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State | NE
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Zip | 68046-8082
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Country | US
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Telephone | 402-932-3643
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Fax | 402-932-3642
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. FITZGERALD O TAMBE
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Credential | LPN
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Telephone | 402-932-3643
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | HHA200901
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License Number State | NE
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