MEDICARE: JEREMIAH I SAMUEL HHA

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	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1306189055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMIAH I SAMUEL HHA

Provider Business Mailing Address
First Line	:	200 WILMINGTON PL SE APT A
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20032-2426
Country	:	US
Telephone Number	:	202-696-5732
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 WILMINGTON PL SE APT A
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20032-2426
Country	:	US
Telephone Number	:	202-696-5732
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2013
Last Update Date	:	04/01/2013

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