MEDICARE: CC HOME CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1033768528
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CC HOME CARE LLC

Provider Business Mailing Address
First Line	:	9713 BEREA ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19114-1723
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1102 W SOMERVILLE AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19141-2904
Country	:	US
Telephone Number	:	267-331-5253
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MEDITH CHARLES
Credential	:
Telephone Number	:	267-304-6775

Provider Enumeration Date	:	09/06/2019
Last Update Date	:	09/06/2019

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