MEDICARE: PENINSULA HOMECARE COOPERATIVE

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

General Provider Information

NPI Number	:	1568101723
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENINSULA HOMECARE COOPERATIVE

Provider Business Mailing Address
First Line	:	PO BOX 468
Second Line	:
City	:	PORT TOWNSEND
State	:	WA
Zip	:	98368-0468
Country	:	US
Telephone Number	:	360-385-9664
Fax Number	:	360-385-1661

Provider Business Practice Location Address
First Line	:	1017B WATER ST
Second Line	:
City	:	PORT TOWNSEND
State	:	WA
Zip	:	98368-6705
Country	:	US
Telephone Number	:	360-385-9664
Fax Number	:	360-385-1661

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. KIPPI WATERS
Credential	:
Telephone Number	:	360-385-9664

Provider Enumeration Date	:	06/03/2022
Last Update Date	:	06/03/2022

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