Healthcare Provider Details

I. General information

NPI: 1376097865
Provider Name (Legal Business Name): PRISTINE HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2016
Last Update Date: 08/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 MICHENER ST
PHILADELPHIA PA
19115-4320
US

IV. Provider business mailing address

2210 MICHENER ST
PHILADELPHIA PA
19115-4320
US

V. Phone/Fax

Practice location:
  • Phone: 215-969-4343
  • Fax: 215-969-5671
Mailing address:
  • Phone: 215-969-4343
  • Fax: 215-969-5671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number30743601
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number30743601
License Number StatePA

VIII. Authorized Official

Name: MR. JOSH GEORGE
Title or Position: DIRECTOR
Credential:
Phone: 267-255-0203