Provider Demographics
NPI:1003282062
Name:ANGKOR HOMECARE LLC
Entity Type:Organization
Organization Name:ANGKOR HOMECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VANNAK
Authorized Official - Middle Name:
Authorized Official - Last Name:KANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-756-8512
Mailing Address - Street 1:173 PINE ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01851-3112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:173 PINE ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01851-3112
Practice Address - Country:US
Practice Address - Phone:978-455-8466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-13
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health