Provider Demographics
NPI:1407465214
Name:CHURCH ROAD HOME LLC
Entity Type:Organization
Organization Name:CHURCH ROAD HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:GAINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-712-4578
Mailing Address - Street 1:201 TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-9425
Mailing Address - Country:US
Mailing Address - Phone:717-712-4578
Mailing Address - Fax:717-312-8903
Practice Address - Street 1:1669 CHURCH RD
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-1812
Practice Address - Country:US
Practice Address - Phone:717-525-2156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA6701495233Medicaid