MEDICARE: OM HEALTH AND LIFE CARE 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1588271522
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OM HEALTH AND LIFE CARE SERVICES LLC

Provider Business Mailing Address
First Line	:	1661 PALATKA RD SE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32909-5612
Country	:	US
Telephone Number	:	561-506-1447
Fax Number	:

Provider Business Practice Location Address
First Line	:	1661 PALATKA RD SE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32909-5612
Country	:	US
Telephone Number	:	561-506-1447
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	KIANDRA HARDEN
Credential	:
Telephone Number	:	561-506-1447

Provider Enumeration Date	:	09/24/2020
Last Update Date	:	09/24/2020

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