1598069957 NPI number — HOMEBOUND PRIMARY CARE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598069957 NPI number — HOMEBOUND PRIMARY CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOMEBOUND PRIMARY 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:
1598069957
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 208
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WELLINGTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44090-0208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-550-5605
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18211 GIFFORD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WELLINGTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44090-8910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-550-5605
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GUNDER
Authorized Official First Name:
CHRISTEN
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
855-550-5605

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  10202 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1063665024 . This is a "EMPLOYEE NPI" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 3130865 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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