Provider Demographics
NPI:1972641496
Name:LIFE CARE HOME SERVICES OF NORTHWESTERN PENNSYLVANIA LLP
Entity Type:Organization
Organization Name:LIFE CARE HOME SERVICES OF NORTHWESTERN PENNSYLVANIA LLP
Other - Org Name:GREAT LAKES HOME HEALTHCARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DUBOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN
Authorized Official - Phone:814-877-6121
Mailing Address - Street 1:1647 SASSAFRAS ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-1858
Mailing Address - Country:US
Mailing Address - Phone:814-877-6121
Mailing Address - Fax:814-459-1858
Practice Address - Street 1:195 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-1619
Practice Address - Country:US
Practice Address - Phone:814-362-8141
Practice Address - Fax:814-362-9113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 335E00000X
PA8000002064332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007788280016Medicaid
NY03011410Medicaid
PA1007788280016Medicaid