Provider Demographics
NPI:1629697008
Name:HOMETOWN PROVIDER LLC
Entity Type:Organization
Organization Name:HOMETOWN PROVIDER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:AARON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:810-610-7125
Mailing Address - Street 1:9112 N LINDEN RD
Mailing Address - Street 2:
Mailing Address - City:CLIO
Mailing Address - State:MI
Mailing Address - Zip Code:48420-8524
Mailing Address - Country:US
Mailing Address - Phone:810-610-7125
Mailing Address - Fax:
Practice Address - Street 1:9112 N LINDEN RD
Practice Address - Street 2:
Practice Address - City:CLIO
Practice Address - State:MI
Practice Address - Zip Code:48420-8524
Practice Address - Country:US
Practice Address - Phone:810-610-7125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty