MEDICARE: PENROSE AVENUE 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
2	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1720498728
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENROSE AVENUE LLC

Provider Business Mailing Address
First Line	:	6224 PENROSE AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-3040
Country	:	US
Telephone Number	:	866-894-8488
Fax Number	:

Provider Business Practice Location Address
First Line	:	6224 PENROSE AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-3040
Country	:	US
Telephone Number	:	866-894-8488
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PARTNER & CEO
Name	:	RHONDA HARPER
Credential	:	MBA
Telephone Number	:	866-894-8488

Provider Enumeration Date	:	04/30/2014
Last Update Date	:	04/30/2014

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