Provider Demographics
NPI:1942605019
Name:IMMACULATE HOME HEALTHCARE AGENCY LLC
Entity Type:Organization
Organization Name:IMMACULATE HOME HEALTHCARE AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHOMARI
Authorized Official - Middle Name:DEKERMU
Authorized Official - Last Name:WEEDOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-809-5385
Mailing Address - Street 1:79 GRIDIRON RD
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19057-3809
Mailing Address - Country:US
Mailing Address - Phone:610-809-5385
Mailing Address - Fax:
Practice Address - Street 1:79 GRIDIRON RD
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:PA
Practice Address - Zip Code:19057-3809
Practice Address - Country:US
Practice Address - Phone:610-809-5385
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA26083601251E00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health