=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962280800
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETTYS DISTICTIVENESS HOME CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2023
-----------------------------------------------------
Last Update Date | 09/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23842 SW 107TH CT
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33032-6163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-346-6374
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23842 SW 107TH CT
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33032-6163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-346-6374
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. BETTY JEAN RILEY
-----------------------------------------------------
Credential | CNA
-----------------------------------------------------
Telephone | 786-346-3613
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------