=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134651086
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAD HOME CARE GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2017
-----------------------------------------------------
Last Update Date | 03/30/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2370 HIGHWAY 21
-----------------------------------------------------
City | BELLEVIEW
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63623-6315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-697-1190
-----------------------------------------------------
Fax | 573-697-1190
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2370 HIGHWAY 21
-----------------------------------------------------
City | BELLEVIEW
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63623-6315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-697-1190
-----------------------------------------------------
Fax | 573-697-1190
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DORA O LASHLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-697-1190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | LC001528996
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------