MEDICARE: PVHS HOME MEDICAL SUPPLY 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	332B00000X	Durable Medical Equipment & Medical Supplies
2	332BX2000X	Oxygen Equipment & Supplies (DME)

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	:	1720064876
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PVHS HOME MEDICAL SUPPLY LLC

Provider Business Mailing Address
First Line	:	555 E NORTH LN STE 5075
Second Line	:
City	:	CONSHOHOCKEN
State	:	PA
Zip	:	19428-2490
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1420 RIVERSIDE AVE STE 108
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-4380
Country	:	US
Telephone Number	:	970-484-6616
Fax Number	:	970-224-2883

Authorized Official
Title or Position	:	CCO
Name	:	WENDY RUSSALESI
Credential	:
Telephone Number	:	484-246-9499

Provider Enumeration Date	:	12/21/2005
Last Update Date	:	10/14/2025

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