Provider Demographics
NPI:1104585058
Name:BLUEMOON HOME HEALTHCARE LLC
Entity type:Organization
Organization Name:BLUEMOON HOME HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:ISSE
Authorized Official - Last Name:MOHAMUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-321-7065
Mailing Address - Street 1:5705 TAMARACK BLVD APT F
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-3776
Mailing Address - Country:US
Mailing Address - Phone:614-721-0714
Mailing Address - Fax:
Practice Address - Street 1:5705 TAMARACK BLVD APT F
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-3776
Practice Address - Country:US
Practice Address - Phone:614-721-0714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health