=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225875347
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOMBA HOME CARE ARKANSAS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2024
-----------------------------------------------------
Last Update Date | 05/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 W CAPITOL AVE STE 1700
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72201-3438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-553-3495
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5565 GLENRIDGE CONNECTOR STE 500
-----------------------------------------------------
City | SANDY SPRINGS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342-4796
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NPI MANAGER
-----------------------------------------------------
Name | ELAZAR HUISMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-418-7484
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------