=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669708236
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARIPOSA PRIMARY HOME CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2009
-----------------------------------------------------
Last Update Date | 11/02/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10107 MONTOYA DR
-----------------------------------------------------
City | LAREDO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78045-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-218-2180
-----------------------------------------------------
Fax | 210-438-8102
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10107 MONTOYA DR
-----------------------------------------------------
City | LAREDO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78045-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-218-2180
-----------------------------------------------------
Fax | 210-438-8102
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. MARK HARLEY FERGUSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-218-2180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------