=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760020507
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOME CARE PRIME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2019
-----------------------------------------------------
Last Update Date | 12/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2487 S BASSETT ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48217-1650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-610-1215
-----------------------------------------------------
Fax | 313-228-5584
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2487 S BASSETT ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48217-1650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-610-1215
-----------------------------------------------------
Fax | 313-228-5584
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HOME CARE
-----------------------------------------------------
Name | MRS. NICOLE CORBETT -SHEDD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-610-1215
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------