MEDICARE: NIMROD NATION ENTERPRISE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	174200000X	Meals Provider
2	177F00000X	Lodging Provider
3	251300000X	Local Education Agency (LEA)
4	251B00000X	Case Management Agency
5	251E00000X	Home Health Agency
6	251S00000X	Community/Behavioral Health Agency
7	251T00000X	PACE Provider Organization
8	252Y00000X	Early Intervention Provider Agency
9	253Z00000X	In Home Supportive Care Agency
10	261QM0855X	Adolescent and Children Mental Health Clinic/Center
11	261QV0200X	VA Clinic/Center
12	343900000X	Non-emergency Medical Transport (VAN)
13	261QA0600X	Adult Day Care Clinic/Center

General Provider Information

NPI Number	:	1275252652
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NIMROD NATION ENTERPRISE LLC

Provider Business Mailing Address
First Line	:	1700 W POLO RD STE 128
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-1821
Country	:	US
Telephone Number	:
Fax Number	:	318-626-7179

Provider Business Practice Location Address
First Line	:	1700 W POLO RD STE 128
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-1821
Country	:	US
Telephone Number	:	318-230-8414
Fax Number	:	318-626-7179

Authorized Official
Title or Position	:	OWNER
Name	:	MR. RASBY G MASON III
Credential	:
Telephone Number	:	318-230-8410

Provider Enumeration Date	:	08/26/2022
Last Update Date	:	08/26/2022

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Directions to “NIMROD NATION ENTERPRISE LLC ” Practice Location

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