Provider Demographics
NPI:1801816418
Name:MCLEAN HOME HEALTH AGENCY, INC.
Entity Type:Organization
Organization Name:MCLEAN HOME HEALTH AGENCY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:FISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-779-2485
Mailing Address - Street 1:PO BOX 47
Mailing Address - Street 2:
Mailing Address - City:MCLEAN
Mailing Address - State:TX
Mailing Address - Zip Code:79057-0047
Mailing Address - Country:US
Mailing Address - Phone:806-779-2485
Mailing Address - Fax:806-779-2690
Practice Address - Street 1:603 N. GROVE ST.
Practice Address - Street 2:
Practice Address - City:MCLEAN
Practice Address - State:TX
Practice Address - Zip Code:79057-0047
Practice Address - Country:US
Practice Address - Phone:806-779-2485
Practice Address - Fax:806-779-2690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX002414251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0247140Medicaid
TX45D0887380OtherCLIA CERT OF WAIVER
TX0130387Medicaid
677563Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER