MEDICARE: PROFESSIONAL CARE HOME CARE AGENCY, INC.

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	251E00000X	Home Health Agency	HP0275000	NJ

General Provider Information

NPI Number	:	1083105175
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL CARE HOME CARE AGENCY, INC.

Provider Business Mailing Address
First Line	:	2050 CENTER AVE STE 318
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-4932
Country	:	US
Telephone Number	:	347-683-5773
Fax Number	:	201-944-4029

Provider Business Practice Location Address
First Line	:	2050 CENTER AVE STE 318
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-4932
Country	:	US
Telephone Number	:	347-683-5773
Fax Number	:	201-944-4029

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. NELLIE KRIVOSHEYEV
Credential	:
Telephone Number	:	347-683-5773

Provider Enumeration Date	:	05/23/2018
Last Update Date	:	05/23/2018

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