Provider Demographics
NPI:1396836219
Name:EXTENDED NURSING PERSONNEL CHHA, LLC
Entity Type:Organization
Organization Name:EXTENDED NURSING PERSONNEL CHHA, LLC
Other - Org Name:EXTENDED HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-356-4200
Mailing Address - Street 1:2003 CONEY ISLAND AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-2328
Mailing Address - Country:US
Mailing Address - Phone:212-356-4200
Mailing Address - Fax:917-793-4279
Practice Address - Street 1:2003 CONEY ISLAND AVE FL 3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-2328
Practice Address - Country:US
Practice Address - Phone:212-356-4200
Practice Address - Fax:917-793-4279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7002653251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01973037Medicaid
NY337414Medicare Oscar/Certification