=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134643471
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GAHANNA HOME HEALTHCARE AGENCY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2017
-----------------------------------------------------
Last Update Date | 07/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7451 BUNKER RIDGE CT
-----------------------------------------------------
City | BLACKLICK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-766-9112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7451 BUNKER RIDGE CT
-----------------------------------------------------
City | BLACKLICK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-766-9112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | JAMILA A. IDRIS
-----------------------------------------------------
Credential | CNA
-----------------------------------------------------
Telephone | 732-877-9776
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163WH0200X
-----------------------------------------------------
Taxonomy Name | Home Health Registered Nurse
-----------------------------------------------------
License Number | NA0008184328
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------