=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982652194
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDWEST HMA HOME HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2006
-----------------------------------------------------
Last Update Date | 08/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1117 S DOUGLAS BLVD SUITES A & B
-----------------------------------------------------
City | MIDWEST CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73130-5262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-736-6925
-----------------------------------------------------
Fax | 405-736-0719
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1117 S DOUGLAS BLVD SUITES A & B
-----------------------------------------------------
City | MIDWEST CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73130-5262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-736-6925
-----------------------------------------------------
Fax | 405-736-0719
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | LAURIE J HOLTSFORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-465-7466
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 7200
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------