MEDICARE: GENESIS RESTORE HOME HEALTHCARE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251E00000X	Home Health Agency
2	3747P1801X	Personal Care Attendant
3	3747A0650X	Attendant Care Provider

General Provider Information

NPI Number	:	1386418994
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS RESTORE HOME HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	5665 ARAPAHO RD APT 827
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75248-3491
Country	:	US
Telephone Number	:	651-233-0937
Fax Number	:

Provider Business Practice Location Address
First Line	:	5665 ARAPAHO RD APT 827
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75248-3491
Country	:	US
Telephone Number	:	651-233-0937
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID NKWONTA
Credential	:
Telephone Number	:	651-233-0937

Provider Enumeration Date	:	11/14/2023
Last Update Date	:	11/14/2023

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