MEDICARE: BLUEMOON HOME HEALTHCARE 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	:	1104585058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUEMOON HOME HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	5705 TAMARACK BLVD APT F
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43229-3776
Country	:	US
Telephone Number	:	614-721-0714
Fax Number	:

Provider Business Practice Location Address
First Line	:	5705 TAMARACK BLVD APT F
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43229-3776
Country	:	US
Telephone Number	:	614-721-0714
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MOHAMED ISSE MOHAMUD
Credential	:
Telephone Number	:	619-321-7065

Provider Enumeration Date	:	12/08/2021
Last Update Date	:	12/08/2021

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