Provider Demographics
NPI:1487019436
Name:CELEMIAH HOME AND COMMUNITY SUPPORT SERVICE AGENCY
Entity Type:Organization
Organization Name:CELEMIAH HOME AND COMMUNITY SUPPORT SERVICE AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:KIPNGETICH
Authorized Official - Last Name:CHUMBA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:512-825-6440
Mailing Address - Street 1:17804 BRIDGEFARMER BLVD
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-3484
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17804 BRIDGEFARMER BLVD
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-3484
Practice Address - Country:US
Practice Address - Phone:512-825-6440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX833814251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health