Provider Demographics
NPI:1780664953
Name:PENINSULA HOME CARE AT NANTICOKE LLC
Entity Type:Organization
Organization Name:PENINSULA HOME CARE AT NANTICOKE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEBUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-731-2403
Mailing Address - Street 1:2459 WILKINSON BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5669
Mailing Address - Country:US
Mailing Address - Phone:704-831-5059
Mailing Address - Fax:
Practice Address - Street 1:501 HEALTH SERVICES DR
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-5782
Practice Address - Country:US
Practice Address - Phone:302-629-4914
Practice Address - Fax:302-629-6542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-21
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE087036251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE087036Medicare Oscar/Certification