Provider Demographics
NPI:1720455264
Name:FAMILY SUPPORT CIRCLE, INC
Entity Type:Organization
Organization Name:FAMILY SUPPORT CIRCLE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELNA
Authorized Official - Middle Name:
Authorized Official - Last Name:POULARD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:404-917-9765
Mailing Address - Street 1:2059 E CHELTEN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19138-3043
Mailing Address - Country:US
Mailing Address - Phone:267-335-5857
Mailing Address - Fax:267-385-6119
Practice Address - Street 1:2059 E CHELTEN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19138-3043
Practice Address - Country:US
Practice Address - Phone:267-335-5857
Practice Address - Fax:267-385-6119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA22343601385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA22343601OtherHOME CARE LICENSE NUMBER
PA1000006490002Medicaid