1104099191 NPI number — LIFE CARE HOME SERVICES OF NORTHWESTERN PENNSYLVANIA LLP

Table of content: (NPI 1104099191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104099191 NPI number — LIFE CARE HOME SERVICES OF NORTHWESTERN PENNSYLVANIA LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFE CARE HOME SERVICES OF NORTHWESTERN PENNSYLVANIA LLP
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:
GREAT LAKES HOME HEALTHCARE SERVICES
Provider Other Organization Name Type Code:
3
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:
1104099191
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1647 SASSAFRAS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ERIE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16502-1858
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-877-6121
Provider Business Mailing Address Fax Number:
814-459-1858

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1647 SASSAFRAS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ERIE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16502-1858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-877-6121
Provider Business Practice Location Address Fax Number:
814-877-6297
Provider Enumeration Date:
04/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DUBOWSKI
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
814-877-6121

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  006305 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 164W00000X , with the licence number: 006305 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , with the licence number: 006305 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1007788280007 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1379 . This is a "HIGHMARK BC BS" identifier . This identifiers is of the category "OTHER".




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