MEDICARE: EVE RESIDENTIAL SUPPORT 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	:	1588296396
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVE RESIDENTIAL SUPPORT LLC

Provider Business Mailing Address
First Line	:	2165 CORNELL ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43219-3518
Country	:	US
Telephone Number	:	614-446-5014
Fax Number	:

Provider Business Practice Location Address
First Line	:	2165 CORNELL ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43219-3518
Country	:	US
Telephone Number	:	614-446-5014
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ANTHONY ZAZAYMA BOAKAI
Credential	:
Telephone Number	:	614-446-5014

Provider Enumeration Date	:	02/10/2020
Last Update Date	:	02/10/2020

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