MEDICARE: EXTENDED NURSING PERSONNEL CHHA, 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	7002653	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396836219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXTENDED NURSING PERSONNEL CHHA, LLC

Provider Business Mailing Address
First Line	:	2003 CONEY ISLAND AVE FL 3
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11223-2328
Country	:	US
Telephone Number	:	212-356-4200
Fax Number	:	917-793-4279

Provider Business Practice Location Address
First Line	:	2003 CONEY ISLAND AVE FL 3
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11223-2328
Country	:	US
Telephone Number	:	212-356-4200
Fax Number	:	917-793-4279

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JACLYN DIANA
Credential	:
Telephone Number	:	212-356-4200

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	03/28/2024

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