=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861624967
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIERRA PRIDE HOME HEALTHCARE AGENCY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2009
-----------------------------------------------------
Last Update Date | 08/22/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29333 TRAILWOOD DR
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48092-4696
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-321-7206
-----------------------------------------------------
Fax | 585-619-9312
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29333 TRAILWOOD DR
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48092-4696
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-321-7206
-----------------------------------------------------
Fax | 585-619-9312
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO AND ADMINISTRATOR
-----------------------------------------------------
Name | MRS. BRIDGET HAMED
-----------------------------------------------------
Credential | REGISTERED NURSE
-----------------------------------------------------
Telephone | 248-321-7206
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------