Provider Demographics
NPI:1790767622
Name:SUCCESSFUL AGING CARE NET INC
Entity Type:Organization
Organization Name:SUCCESSFUL AGING CARE NET INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:INNOCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:ONWUBIKO
Authorized Official - Suffix:
Authorized Official - Credentials:MSHA, MSGS
Authorized Official - Phone:484-461-8711
Mailing Address - Street 1:48 GARRETT RD
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-2303
Mailing Address - Country:US
Mailing Address - Phone:484-461-8711
Mailing Address - Fax:610-284-4170
Practice Address - Street 1:48 GARRETT RD
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-2303
Practice Address - Country:US
Practice Address - Phone:484-461-8711
Practice Address - Fax:610-284-4170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA80200501251E00000X
PA5418770001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011366320001Medicaid
PA1011366320002Medicaid
PA80200501OtherHOME HEALTHCARE LICENSE
PA80200501OtherHOME HEALTHCARE LICENSE
PA1011366320002Medicaid