=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679169270
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAGLE'S NEST HOME CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2020
-----------------------------------------------------
Last Update Date | 12/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 GARRETT RD STE 1
-----------------------------------------------------
City | UPPER DARBY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19082-2302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-247-7952
-----------------------------------------------------
Fax | 610-822-7052
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 GARRETT RD STE 1
-----------------------------------------------------
City | UPPER DARBY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19082-2302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-247-7952
-----------------------------------------------------
Fax | 610-822-7052
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | SUSANNAH J WHITE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-200-9394
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------