=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134680960
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ON BEHALF OF GOD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2019
-----------------------------------------------------
Last Update Date | 12/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5012 HONEYSUCKLE LN APT 207
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23321-3275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-401-0618
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 505 CUMBERLAND AVE
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-392-3011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TRAVIS JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-401-0618
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------