MEDICARE: ANI CDSA LIMITED LIABILITY COMPANY

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	251X00000X	Supports Brokerage Agency

General Provider Information

NPI Number	:	1801130265
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANI CDSA LIMITED LIABILITY COMPANY

Provider Business Mailing Address
First Line	:	1145 RANCH VALLEY DR
Second Line	:
City	:	DESOTO
State	:	TX
Zip	:	75115-3524
Country	:	US
Telephone Number	:	972-228-4100
Fax Number	:	972-228-4100

Provider Business Practice Location Address
First Line	:	1145 RANCH VALLEY DR
Second Line	:
City	:	DESOTO
State	:	TX
Zip	:	75115-3524
Country	:	US
Telephone Number	:	972-228-4100
Fax Number	:	972-228-4100

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	ORITSEBEMIGHO EDEGBELE
Credential	:
Telephone Number	:	972-228-4100

Provider Enumeration Date	:	11/23/2012
Last Update Date	:	11/23/2012

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