Healthcare Provider Details

I. General information

NPI: 1457772808
Provider Name (Legal Business Name): COMMONWEALTH SUPPORTIVE SERVICES,LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/01/2014
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 MACDADE BLVD
FOLSOM PA
19033-1313
US

IV. Provider business mailing address

1602 MACDADE BLVD
FOLSOM PA
19033-1313
US

V. Phone/Fax

Practice location:
  • Phone: 267-207-1941
  • Fax:
Mailing address:
  • Phone: 267-207-1941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number State

VIII. Authorized Official

Name: THOMAS KARGBO
Title or Position: C.E.O.
Credential:
Phone: 267-207-1941