Provider Demographics
NPI:1073011268
Name:AT HOME COMFORT CARE LLC
Entity Type:Organization
Organization Name:AT HOME COMFORT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-235-2429
Mailing Address - Street 1:1042 ANSEL RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-2268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1042 ANSEL RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-2268
Practice Address - Country:US
Practice Address - Phone:216-235-2429
Practice Address - Fax:216-235-2429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1548627987Medicaid