MEDICARE: INDEPENDENT SENIOR HOME SERVICES

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	2008-237117-R	VA

General Provider Information

NPI Number	:	1396915195
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT SENIOR HOME SERVICES

Provider Business Mailing Address
First Line	:	4599 QUAKER DR
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23437-9026
Country	:	US
Telephone Number	:	757-478-3884
Fax Number	:

Provider Business Practice Location Address
First Line	:	4599 QUAKER DR
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23437-9026
Country	:	US
Telephone Number	:	757-478-3884
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. STACEY N PHILLIPS
Credential	:	CERTIFIED NURSE AIDE
Telephone Number	:	757-478-3884

Provider Enumeration Date	:	03/07/2008
Last Update Date	:	03/07/2008

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