Provider Demographics
NPI:1356747588
Name:EASTERN SHORE AREA AGENCY ON AGING/COMMUNITY ACTION AGENCY
Entity type:Organization
Organization Name:EASTERN SHORE AREA AGENCY ON AGING/COMMUNITY ACTION AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-442-9652
Mailing Address - Street 1:5432 BAYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:EXMORE
Mailing Address - State:VA
Mailing Address - Zip Code:23350-3936
Mailing Address - Country:US
Mailing Address - Phone:757-442-9652
Mailing Address - Fax:757-442-9303
Practice Address - Street 1:5432 BAYSIDE RD
Practice Address - Street 2:
Practice Address - City:EXMORE
Practice Address - State:VA
Practice Address - Zip Code:23350-3936
Practice Address - Country:US
Practice Address - Phone:757-442-9652
Practice Address - Fax:757-442-9303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHCO-15709251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0163372003Medicaid
VA0167908513Medicaid
VA0087005085Medicaid