=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376549410
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESIDENTIAL CLINICAL SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2005
-----------------------------------------------------
Last Update Date | 08/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8102 GEORGIA ST FL 2
-----------------------------------------------------
City | MERRILLVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46410-6225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-736-5718
-----------------------------------------------------
Fax | 219-736-5720
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 W 78TH PL
-----------------------------------------------------
City | MERRILLVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46410-5468
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-736-5718
-----------------------------------------------------
Fax | 219-736-5720
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR/PRESIDENT
-----------------------------------------------------
Name | DR. AHMED A. MOHAMED
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 219-736-5718
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 04-005307-1
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------