Provider Demographics
NPI:1710536024
Name:PHASE ONE HOME HEALTH LLC
Entity Type:Organization
Organization Name:PHASE ONE HOME HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:M
Authorized Official - Last Name:KINARD
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:215-850-1928
Mailing Address - Street 1:640 COWPATH RD # 186
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-1563
Mailing Address - Country:US
Mailing Address - Phone:215-850-1928
Mailing Address - Fax:
Practice Address - Street 1:109 CLAYTON CT
Practice Address - Street 2:
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-1828
Practice Address - Country:US
Practice Address - Phone:215-850-1928
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1036532190001Medicaid