=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962464032
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRINICARE HOME HEALTH, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2006
-----------------------------------------------------
Last Update Date | 02/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1222 E ARAPAHO RD 322
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75081-2478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-828-1132
-----------------------------------------------------
Fax | 469-828-1074
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1222 E ARAPAHO RD 322
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75081-2478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-828-1132
-----------------------------------------------------
Fax | 469-828-1074
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR/DIRECTOR OF NURSING
-----------------------------------------------------
Name | SHAWNA BOUDREAUX
-----------------------------------------------------
Credential | BS BA
-----------------------------------------------------
Telephone | 469-828-1132
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 007996
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------