MEDICARE: EXCEPTIONAL PROVIDER SERVICE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1013511153
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXCEPTIONAL PROVIDER SERVICE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 632
Second Line	:
City	:	LEMING
State	:	TX
Zip	:	78050-0632
Country	:	US
Telephone Number	:	210-579-0223
Fax Number	:	210-579-0242

Provider Business Practice Location Address
First Line	:	8546 BROADWAY STE 206
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-6340
Country	:	US
Telephone Number	:	210-579-0223
Fax Number	:	210-579-0242

Authorized Official
Title or Position	:	CEO/ADMINISTRATOR
Name	:	DANIEL CASTILLO
Credential	:
Telephone Number	:	210-579-0223

Provider Enumeration Date	:	11/30/2020
Last Update Date	:	11/30/2020

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