Provider Demographics
NPI:1083366918
Name:SHORE DRIVE HOME HEALTH LLC
Entity Type:Organization
Organization Name:SHORE DRIVE HOME HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-839-8157
Mailing Address - Street 1:PO BOX 1306
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-1306
Mailing Address - Country:US
Mailing Address - Phone:757-839-8157
Mailing Address - Fax:
Practice Address - Street 1:854 GRANBY STREET
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510
Practice Address - Country:US
Practice Address - Phone:757-839-8157
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health