Provider Demographics
NPI:1710364542
Name:HEPHZIBAH BEULAH INC
Entity Type:Organization
Organization Name:HEPHZIBAH BEULAH INC
Other - Org Name:LATOM CARE GROUPS FACILITIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:OMOLARA
Authorized Official - Middle Name:O
Authorized Official - Last Name:DARAMOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-338-9637
Mailing Address - Street 1:12808 W AIRPORT BLVD
Mailing Address - Street 2:SUITE #348
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-6184
Mailing Address - Country:US
Mailing Address - Phone:832-338-9637
Mailing Address - Fax:
Practice Address - Street 1:12808 W AIRPORT BLVD
Practice Address - Street 2:SUITE #348
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-6184
Practice Address - Country:US
Practice Address - Phone:832-338-9637
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEPHZIBAH BEULAH INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX013702251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX747765Medicare PIN