Provider Demographics
NPI:1679036487
Name:AVALON AT HOME, LLC
Entity Type:Organization
Organization Name:AVALON AT HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ADIAM
Authorized Official - Middle Name:TESFAHUNEY
Authorized Official - Last Name:KELETA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-330-2912
Mailing Address - Street 1:35 NANCY LN
Mailing Address - Street 2:
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335
Mailing Address - Country:US
Mailing Address - Phone:215-330-2912
Mailing Address - Fax:215-330-2913
Practice Address - Street 1:1500 WALNUT ST STE 1900
Practice Address - Street 2:
Practice Address - City:DOWNINGTOWN
Practice Address - State:PA
Practice Address - Zip Code:19335
Practice Address - Country:US
Practice Address - Phone:215-330-2912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA26300539Medicaid