MEDICARE: AT EASE DIALYSIS SUPPORT, 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	3827564	PA

General Provider Information

NPI Number	:	1710279674
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AT EASE DIALYSIS SUPPORT, LLC

Provider Business Mailing Address
First Line	:	1167 CLEVELAND ST.
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-2909
Country	:	US
Telephone Number	:	267-333-5150
Fax Number	:

Provider Business Practice Location Address
First Line	:	1167 CLEVELAND ST.
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-2909
Country	:	US
Telephone Number	:	267-333-5150
Fax Number	:

Authorized Official
Title or Position	:	OWNER/TECHNICIAN
Name	:	MR. LOUIS TAYLOR
Credential	:
Telephone Number	:	267-333-5150

Provider Enumeration Date	:	05/11/2011
Last Update Date	:	05/11/2011

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