Healthcare Provider Details

I. General information

NPI: 1013530443
Provider Name (Legal Business Name): DISTINCTIVE HOMECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9444 KIRKWOOD RD
PHILADELPHIA PA
19114-2606
US

IV. Provider business mailing address

9444 KIRKWOOD RD
PHILADELPHIA PA
19114-2606
US

V. Phone/Fax

Practice location:
  • Phone: 267-815-7307
  • Fax:
Mailing address:
  • Phone: 267-815-7307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN DEGRAFT KOOMSON
Title or Position: PRESIDENT
Credential: RN
Phone: 267-815-7307