MEDICARE: BOOMERS PERSONAL CARE 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	253Z00000X	In Home Supportive Care Agency		MO

General Provider Information

NPI Number	:	1063879781
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOOMERS PERSONAL CARE LLC

Provider Business Mailing Address
First Line	:	1208 BROOKLYN AVE
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64127
Country	:	US
Telephone Number	:	816-785-3638
Fax Number	:

Provider Business Practice Location Address
First Line	:	1208 BROOKLYN AVE
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64127-1912
Country	:	US
Telephone Number	:	816-785-3638
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ABDIRASHID ABDULLAHI BASHIR
Credential	:
Telephone Number	:	816-785-3638

Provider Enumeration Date	:	01/26/2016
Last Update Date	:	07/21/2022

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