Provider Demographics
NPI:1720588221
Name:EMINENCE HEALTHCARE STAFFING AGENCY LLC.
Entity Type:Organization
Organization Name:EMINENCE HEALTHCARE STAFFING AGENCY LLC.
Other - Org Name:EMINENCE HEALTH & NOTARY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, MD, CEO
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:DAVONNE
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:AAS
Authorized Official - Phone:866-350-6400
Mailing Address - Street 1:2015 W WESTERN AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46619-3558
Mailing Address - Country:US
Mailing Address - Phone:866-350-6400
Mailing Address - Fax:
Practice Address - Street 1:2015 W WESTERN AVE STE 201
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46619-3558
Practice Address - Country:US
Practice Address - Phone:866-350-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-20
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27075427A164W00000X
261QH0100X, 291U00000X, 305S00000X, 332900000X, 332B00000X
IN347C00000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No305S00000XManaged Care OrganizationsPoint of Service
No332900000XSuppliersNon-Pharmacy Dispensing Site
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No347C00000XTransportation ServicesPrivate Vehicle
No385H00000XRespite Care FacilityRespite Care