MEDICARE: EDICARE PROFESSIONAL HEALTHCARE SERVICES, INC

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	010365	TX

General Provider Information

NPI Number	:	1316001191
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDICARE PROFESSIONAL HEALTHCARE SERVICES, INC

Provider Business Mailing Address
First Line	:	2000 S DAIRY ASHFORD ST
Second Line	:	SUITE #305
City	:	HOUSTON
State	:	TX
Zip	:	77077-5700
Country	:	US
Telephone Number	:	281-568-4573
Fax Number	:	281-879-8411

Provider Business Practice Location Address
First Line	:	2000 S DAIRY ASHFORD ST
Second Line	:	SUITE #305
City	:	HOUSTON
State	:	TX
Zip	:	77077-5700
Country	:	US
Telephone Number	:	281-568-4573
Fax Number	:	281-879-8411

Authorized Official
Title or Position	:	ALT ADMINISTRATOR
Name	:	EDOSASERE LEE OMORUYI
Credential	:	BSCE
Telephone Number	:	281-568-4573

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	02/01/2012

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