Provider Demographics
NPI:1518678044
Name:HISTORIC HEALTHCARE SERVICES, LLC
Entity Type:Organization
Organization Name:HISTORIC HEALTHCARE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOEBRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMNYUYTAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-495-8331
Mailing Address - Street 1:1629 K ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20006-1602
Mailing Address - Country:US
Mailing Address - Phone:301-332-9778
Mailing Address - Fax:
Practice Address - Street 1:1629 K ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20006-1602
Practice Address - Country:US
Practice Address - Phone:301-332-9778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No253Z00000XAgenciesIn Home Supportive Care