=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801525803
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOMETOWN HEALTHCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2022
-----------------------------------------------------
Last Update Date | 09/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5575 N. COUNCIL AVE
-----------------------------------------------------
City | BLANCHARD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-597-2194
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5575 N. COUNCIL AVE
-----------------------------------------------------
City | BLANCHARD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-597-2194
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMBER GARRETT
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 405-597-2194
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------