=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548877574
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REST ASSURED HOME CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2020
-----------------------------------------------------
Last Update Date | 09/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 222 RIVENDALE DR
-----------------------------------------------------
City | WEST FORK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72774-3208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-313-4459
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 222 RIVENDALE DR
-----------------------------------------------------
City | WEST FORK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72774-3208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-313-4459
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DENIECE SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 479-313-4459
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------