Healthcare Provider Details

I. General information

NPI: 1730369315
Provider Name (Legal Business Name): PENNSYLVANIA HOME CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2007
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 HIGHWAY 315
WILKES BARRE PA
18702-6943
US

IV. Provider business mailing address

1106 HIGHWAY 315
WILKES BARRE PA
18702-6943
US

V. Phone/Fax

Practice location:
  • Phone: 570-824-0023
  • Fax: 570-824-1666
Mailing address:
  • Phone: 570-824-0023
  • Fax: 570-824-1666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number719005
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1007417570003
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: MRS. CAROL L SMITH
Title or Position: CORP DIRECTOR BILLING
Credential:
Phone: 610-205-2440