MEDICARE: TRICOUNTY PHYSICIAN HOMECARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QA0505X	Adult Medicine Physician	25MBO5511300	NJ

General Provider Information

NPI Number	:	1710221346
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRICOUNTY PHYSICIAN HOMECARE LLC

Provider Business Mailing Address
First Line	:	716 NEWMAN SPRINGS RD
Second Line	:	BOX 231
City	:	LINCROFT
State	:	NJ
Zip	:	07738-1523
Country	:	US
Telephone Number	:	908-925-9309
Fax Number	:	908-925-7910

Provider Business Practice Location Address
First Line	:	716 NEWMAN SPRINGS RD
Second Line	:	BOX 231
City	:	LINCROFT
State	:	NJ
Zip	:	07738-1523
Country	:	US
Telephone Number	:	908-925-9309
Fax Number	:	908-925-7910

Authorized Official
Title or Position	:	D.O.
Name	:	DR. KEVIN E. LUKENDA
Credential	:	D.O.
Telephone Number	:	908-925-9309

Provider Enumeration Date	:	11/20/2012
Last Update Date	:	11/20/2012

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