=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881028298
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVE MARIA REGINA HEALTH SYSTEMS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2013
-----------------------------------------------------
Last Update Date | 04/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4008 PEPPERWOOD DR
-----------------------------------------------------
City | ANTIOCH
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37013-1667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-530-8111
-----------------------------------------------------
Fax | 615-280-2538
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4008 PEPPERWOOD DR
-----------------------------------------------------
City | ANTIOCH
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37013-1667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-530-8111
-----------------------------------------------------
Fax | 615-280-2538
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROJECT MANAGER / PRESIDENT
-----------------------------------------------------
Name | IFEYINWA AGHOLOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-530-8111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | 1000000012695
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 1000000012695
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number | 1000000012695
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 1000000012695
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
=====================================================
Legacy Identifiers
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | H445771
-----------------------------------------------------
Identifier Type | MEDICAID
-----------------------------------------------------
Identifier State | TN
-----------------------------------------------------
Identifier Issuer |
-----------------------------------------------------
Identifier #2
-----------------------------------------------------
Identifier Code | T000431
-----------------------------------------------------
Identifier Type | MEDICAID
-----------------------------------------------------
Identifier State | TN
-----------------------------------------------------
Identifier Issuer |
-----------------------------------------------------
=====================================================
Proprietary Identifiers Ever Reported
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | H445771
-----------------------------------------------------
Identifier Type | MEDICAID
-----------------------------------------------------
Identifier State | TN
-----------------------------------------------------
Identifier Issuer |
-----------------------------------------------------
Identifier #2
-----------------------------------------------------
Identifier Code | T000431
-----------------------------------------------------
Identifier Type | MEDICAID
-----------------------------------------------------
Identifier State | TN
-----------------------------------------------------
Identifier Issuer |
-----------------------------------------------------