Provider Demographics
NPI:1124716527
Name:MOMBA HOME CARE IND, LLC
Entity type:Organization
Organization Name:MOMBA HOME CARE IND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELIEZER
Authorized Official - Middle Name:
Authorized Official - Last Name:AVTZON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-902-7022
Mailing Address - Street 1:150 ZEBLIN RD
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30342-2048
Mailing Address - Country:US
Mailing Address - Phone:718-902-7022
Mailing Address - Fax:
Practice Address - Street 1:550 CONGRESSIONAL BLVD STE 115
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5644
Practice Address - Country:US
Practice Address - Phone:317-765-0016
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-25
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care