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General NPI Number Information
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NPI Number | 1982185369
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Entity Type | Organization
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Legal Business Name | VITA BLUE HOMECARE LLC
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Dates
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Enumeration Date | 08/23/2018
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Last Update Date | 08/23/2018
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Provider Practice Location Address
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Address Line | 2836 TREMONT ST 2
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City | PHILADELPHIA
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State | PA
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Zip | 19136-1025
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Country | US
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Telephone | 610-601-4591
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Fax |
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Provider Business Mailing Address
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Address Line | 2836 TREMONT ST 2
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City | PHILADELPHIA
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State | PA
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Zip | 19136-1025
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Country | US
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Telephone | 610-601-4591
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/ADMINISTRATOR
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Name | DOMINIQUE DURAN
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Credential | RN
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Telephone | 267-979-1481
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 36523601
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License Number State | PA
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