=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609420090
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VANCLEEF PERSONAL CARE HOMES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2019
-----------------------------------------------------
Last Update Date | 07/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1060 E COUNTY LINE RD STE 3A-328
-----------------------------------------------------
City | RIDGELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39157-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-441-1910
-----------------------------------------------------
Fax | 414-386-7918
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1060 E COUNTY LINE RD STE 3A-328
-----------------------------------------------------
City | RIDGELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39157-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-441-1910
-----------------------------------------------------
Fax | 414-386-7918
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JERMAINE YOUNG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-441-1910
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 376J00000X
-----------------------------------------------------
Taxonomy Name | Homemaker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------