1386141661 NPI number — EDIRA FAMILY HOME CARE LLC

Table of content: (NPI 1386141661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386141661 NPI number — EDIRA FAMILY HOME CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDIRA FAMILY HOME CARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386141661
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
EDIRA FAMILY HOME CARE LLC
Provider Second Line Business Mailing Address:
63-52 108 STREET LOWER LEVEL
Provider Business Mailing Address City Name:
FOREST HILLS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11375
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-293-5250
Provider Business Mailing Address Fax Number:
718-830-6211

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
EDIRA FAMILY HOME CARE LLC
Provider Second Line Business Practice Location Address:
63-52 108 STREET LOWER LEVEL
Provider Business Practice Location Address City Name:
FOREST HILLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-293-5250
Provider Business Practice Location Address Fax Number:
718-830-6211
Provider Enumeration Date:
04/12/2018

Additional Information

Authorized Official

Authorized Official Last Name:
KORNEYEVA
Authorized Official First Name:
IRINA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
917-293-5250

Provider Taxonomy Codes

  • Taxonomy code: 251J00000X , with the licence number:  2546L001 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 374U00000X , with the licence number: 2546L001 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2546L001 . This is a "HOME CARE SERVICE AGENCY LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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