MEDICARE: DELTA HOME CARE 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	:	1982481511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DELTA HOME CARE LLC

Provider Business Mailing Address
First Line	:	1923 BEACON RIDGE WAY
Second Line	:
City	:	VAN BUREN
State	:	AR
Zip	:	72956-6125
Country	:	US
Telephone Number	:	479-222-5087
Fax Number	:	949-561-4703

Provider Business Practice Location Address
First Line	:	1923 BEACON RIDGE WAY
Second Line	:
City	:	VAN BUREN
State	:	AR
Zip	:	72956-6125
Country	:	US
Telephone Number	:	479-222-5087
Fax Number	:	949-561-4703

Authorized Official
Title or Position	:	AMBR
Name	:	MOHD DZAIDI MOHD DAUD
Credential	:
Telephone Number	:	479-353-2368

Provider Enumeration Date	:	09/08/2023
Last Update Date	:	09/08/2023

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