=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336611490
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EPA SUPPORTIVE SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2018
-----------------------------------------------------
Last Update Date | 12/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 146 TUDOR DR
-----------------------------------------------------
City | NORTH WALES
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19454-1626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-471-2972
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 146 TUDOR DR
-----------------------------------------------------
City | NORTH WALES
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19454-1626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-471-2972
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | EUGENE ASONYE
-----------------------------------------------------
Credential | BEHAVIORAL SPECIALIS
-----------------------------------------------------
Telephone | 267-471-2972
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------