=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033894860
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GERTS GUARDIN ANGELS HOME CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2023
-----------------------------------------------------
Last Update Date | 06/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1650 S WILTON ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19143-5005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 835-208-0729
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5139 LUDLOW ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19139-3432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-570-0828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CARLISS SAMUEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 835-208-0729
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------