Provider Demographics
NPI:1629285721
Name:CALVARY HOME HEALTH AGENCY, INC.
Entity Type:Organization
Organization Name:CALVARY HOME HEALTH AGENCY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:UDECHUKWU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-654-0720
Mailing Address - Street 1:3198 ROYAL LANE, SUITE 212
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-6918
Mailing Address - Country:US
Mailing Address - Phone:214-654-0720
Mailing Address - Fax:214-654-0722
Practice Address - Street 1:3198 ROYAL LANE, SUITE 212
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75229-6918
Practice Address - Country:US
Practice Address - Phone:214-654-0720
Practice Address - Fax:214-654-0722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008066251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45-7927Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER