=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619177094
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRI COUNTY HOME HEALTH CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2007
-----------------------------------------------------
Last Update Date | 07/23/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5150 YOUNGSTOWN POLAND RD
-----------------------------------------------------
City | YOUNGSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44514-1265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-750-1155
-----------------------------------------------------
Fax | 330-750-1175
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5150 YOUNGSTOWN POLAND RD
-----------------------------------------------------
City | YOUNGSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44514-1265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-750-1155
-----------------------------------------------------
Fax | 330-750-1175
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MR. BRIAN E. FANNON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-750-1155
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------