=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861135428
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FULL OF LIFE PERSONAL CARE SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2022
-----------------------------------------------------
Last Update Date | 04/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1510 HAROLD DR
-----------------------------------------------------
City | ASHDOWN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71822-3104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-667-2100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1510 HAROLD DR
-----------------------------------------------------
City | ASHDOWN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71822-3104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-667-2100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | KYSHIA JOHNSON
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 903-293-4671
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------