Provider Demographics
NPI:1942616214
Name:SELF EMPLOYED
Entity Type:Organization
Organization Name:SELF EMPLOYED
Other - Org Name:SELF EMPLOYED
Other - Org Type:Other Name
Authorized Official - Title/Position:HOME HEALTH AID
Authorized Official - Prefix:MS
Authorized Official - First Name:MERCY
Authorized Official - Middle Name:W
Authorized Official - Last Name:KIBE
Authorized Official - Suffix:
Authorized Official - Credentials:HHA, CNA, CMA
Authorized Official - Phone:614-592-8192
Mailing Address - Street 1:7634 KELVINWAY DR
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-5304
Mailing Address - Country:US
Mailing Address - Phone:614-592-8192
Mailing Address - Fax:
Practice Address - Street 1:7634 KELVINWAY DR
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-5304
Practice Address - Country:US
Practice Address - Phone:614-592-8192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty