MEDICARE: PHILADELPHIA PREMIUM HOMECARE 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	251E00000X	Home Health Agency
2	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1194391730
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHILADELPHIA PREMIUM HOMECARE LLC

Provider Business Mailing Address
First Line	:	4619 LESHER ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19124-3321
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4619 LESHER ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19124-3321
Country	:	US
Telephone Number	:	267-808-9130
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TALISHA THOMPSON
Credential	:
Telephone Number	:	267-808-9130

Provider Enumeration Date	:	06/03/2021
Last Update Date	:	06/03/2021

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