MEDICARE: SHALLOTE AGUM FONCHAM CEO

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	251E00000X	Home Health Agency		OH

General Provider Information

NPI Number	:	1841145323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHALLOTE AGUM FONCHAM CEO

Provider Business Mailing Address
First Line	:	2144 RIVERDALE SQ W
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-4063
Country	:	US
Telephone Number	:	312-532-6886
Fax Number	:

Provider Business Practice Location Address
First Line	:	2144 RIVERDALE SQ W
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-4063
Country	:	US
Telephone Number	:	312-532-6886
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2026
Last Update Date	:	03/02/2026

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Directions to “ SHALLOTE AGUM FONCHAM CEO” Practice Location

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