Provider Demographics
NPI:1013530443
Name:DISTINCTIVE HOMECARE LLC
Entity Type:Organization
Organization Name:DISTINCTIVE HOMECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGRAFT KOOMSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:267-815-7307
Mailing Address - Street 1:9444 KIRKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-2606
Mailing Address - Country:US
Mailing Address - Phone:267-815-7307
Mailing Address - Fax:
Practice Address - Street 1:9444 KIRKWOOD RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-2606
Practice Address - Country:US
Practice Address - Phone:267-815-7307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty