MEDICARE: HEPHZIBAH-BEULAH 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	343800000X	Secured Medical Transport (VAN)
2	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1144162405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEPHZIBAH-BEULAH LLC

Provider Business Mailing Address
First Line	:	14249 LAKE LODGE DR
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77384-1539
Country	:	US
Telephone Number	:	940-231-6643
Fax Number	:	940-231-6643

Provider Business Practice Location Address
First Line	:	14249 LAKE LODGE DR
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77384-1539
Country	:	US
Telephone Number	:	940-231-6643
Fax Number	:	940-231-6643

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. OLUWATAYO GABRIEL ODEYEMI
Credential	:	ODEYEMI
Telephone Number	:	940-231-6643

Provider Enumeration Date	:	04/07/2026
Last Update Date	:	04/07/2026

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Directions to “HEPHZIBAH-BEULAH LLC ” Practice Location

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