Provider Demographics
NPI:1326286485
Name:AGING AND DIVERSE HOME HEALTHCARE SERVICES LLC
Entity Type:Organization
Organization Name:AGING AND DIVERSE HOME HEALTHCARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:215-991-6222
Mailing Address - Street 1:5537 GERMANTOWN AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-2225
Mailing Address - Country:US
Mailing Address - Phone:215-991-6222
Mailing Address - Fax:
Practice Address - Street 1:5537 GERMANTOWN AVE FL 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-2225
Practice Address - Country:US
Practice Address - Phone:215-991-6222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-28
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN527652L251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019540140002OtherMA ID
PA0019540140003Medicaid