MEDICARE: DIVERSIFIED SUPPORTIVE SERVICES 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	16723601	PA
2	251B00000X	Case Management Agency	383203	PA

General Provider Information

NPI Number	:	1922321173
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSIFIED SUPPORTIVE SERVICES LLC

Provider Business Mailing Address
First Line	:	1714 MEMPHIS ST
Second Line	:	SUITE C-8
City	:	PHILADELPHIA
State	:	PA
Zip	:	19125-2700
Country	:	US
Telephone Number	:	215-673-2778
Fax Number	:	215-673-3451

Provider Business Practice Location Address
First Line	:	1714 MEMPHIS ST
Second Line	:	SUITE C-8
City	:	PHILADELPHIA
State	:	PA
Zip	:	19125-2700
Country	:	US
Telephone Number	:	215-673-2778
Fax Number	:	215-673-3451

Authorized Official
Title or Position	:	CEO
Name	:	MRS. RASHEEN BETHEL
Credential	:
Telephone Number	:	215-673-2778

Provider Enumeration Date	:	03/02/2010
Last Update Date	:	02/24/2016

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