MEDICARE: AQUAHAB, LP

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	133NN1002X	Nutrition Education Nutritionist	DN003739	PA
2	133NN1002X	Nutrition Education Nutritionist	DN003889	PA
3	133NN1002X	Nutrition Education Nutritionist	DN002660	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2864330000	OTHER	PA	INDEPENDENCE BLUE CROSS

General Provider Information

NPI Number	:	1679718191
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AQUAHAB, LP

Provider Business Mailing Address
First Line	:	3600 GRANT AVE
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19114-2630
Country	:	US
Telephone Number	:	215-677-0400
Fax Number	:	215-671-1837

Provider Business Practice Location Address
First Line	:	3600 GRANT AVE
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19114-2630
Country	:	US
Telephone Number	:	215-677-0400
Fax Number	:	215-671-1837

Authorized Official
Title or Position	:	BILLING SUPERVISOR
Name	:	DEBORAH SIEDLECKI
Credential	:
Telephone Number	:	215-677-0400

Provider Enumeration Date	:	12/12/2008
Last Update Date	:	12/12/2008

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