=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609653765
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMEN PERSONAL CAREGIVER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2023
-----------------------------------------------------
Last Update Date | 09/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1233 TIANA STREET
-----------------------------------------------------
City | ANNA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75409-1248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-282-0856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1233 TIANA STREET
-----------------------------------------------------
City | ANNA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75409-1248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-282-0856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. SIMON OLUGBENGA ADEYEMI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 401-282-0856
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251X00000X
-----------------------------------------------------
Taxonomy Name | Supports Brokerage Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------