Provider Demographics
NPI:1861116808
Name:THE ROCK HOME VISITING PROVIDER LLC
Entity type:Organization
Organization Name:THE ROCK HOME VISITING PROVIDER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GIRMACHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:HAILE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:773-681-1505
Mailing Address - Street 1:3512 COOKE LN
Mailing Address - Street 2:
Mailing Address - City:MELISSA
Mailing Address - State:TX
Mailing Address - Zip Code:75454-1801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3512 COOKE LN
Practice Address - Street 2:
Practice Address - City:MELISSA
Practice Address - State:TX
Practice Address - Zip Code:75454-1801
Practice Address - Country:US
Practice Address - Phone:773-681-1505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care