MEDICARE: MOMBA HOME CARE GA 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

General Provider Information

NPI Number	:	1174211593
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOMBA HOME CARE GA LLC

Provider Business Mailing Address
First Line	:	150 ZEBLIN RD
Second Line	:
City	:	SANDY SPRINGS
State	:	GA
Zip	:	30342-2048
Country	:	US
Telephone Number	:	718-902-7022
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 ZEBLIN RD
Second Line	:
City	:	SANDY SPRINGS
State	:	GA
Zip	:	30342-2048
Country	:	US
Telephone Number	:	718-902-7022
Fax Number	:

Authorized Official
Title or Position	:	NPI MANAGER
Name	:	ELAZAR HUISMAN
Credential	:
Telephone Number	:	404-418-7484

Provider Enumeration Date	:	04/25/2023
Last Update Date	:	05/29/2025

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