MEDICARE: MATTIE'S HOMECARE SERVICES 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	251E00000X	Home Health Agency	008700	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	S500295940	OTHER	TX	AMERIGROUP

General Provider Information

NPI Number	:	1447304209
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MATTIE'S HOMECARE SERVICES LLC

Provider Business Mailing Address
First Line	:	12003 N OAKS DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78753-2314
Country	:	US
Telephone Number	:	512-833-9026
Fax Number	:	512-719-9028

Provider Business Practice Location Address
First Line	:	12003 N OAKS DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78753-2314
Country	:	US
Telephone Number	:	512-833-9026
Fax Number	:	512-719-9028

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. MATTIE L HENDERSON
Credential	:	L.V.N.
Telephone Number	:	512-833-9026

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	06/20/2008

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