MEDICARE: REBUILDING LIFE AND EMBRACING DEATH LLC DBA ANNETTA'S HOME AWAY FROM H

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251B00000X	Case Management Agency
2	251C00000X	Developmentally Disabled Services Day Training Agency
3	253Z00000X	In Home Supportive Care Agency
4	347E00000X	Transportation Broker
5	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1619641420
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REBUILDING LIFE AND EMBRACING DEATH LLC DBA ANNETTA'S HOME AWAY FROM H

Provider Business Mailing Address
First Line	:	PO BOX 298
Second Line	:
City	:	MOUNT VERNON
State	:	TX
Zip	:	75457-0298
Country	:	US
Telephone Number	:	870-592-0687
Fax Number	:

Provider Business Practice Location Address
First Line	:	927 N GREER BLVD
Second Line	:
City	:	PITTSBURG
State	:	TX
Zip	:	75686-1181
Country	:	US
Telephone Number	:	870-592-0687
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	LASHONDRA BROWN
Credential	:	MA, LMSW, CDP, CAGCS
Telephone Number	:	870-592-0687

Provider Enumeration Date	:	08/04/2021
Last Update Date	:	08/25/2021

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