Provider Demographics
NPI:1811152457
Name:MARY AGNES HOME CARE SERVICE, LLC
Entity type:Organization
Organization Name:MARY AGNES HOME CARE SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-595-3334
Mailing Address - Street 1:12388 WARWICK BLVD STE 301E
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-3857
Mailing Address - Country:US
Mailing Address - Phone:757-595-3334
Mailing Address - Fax:757-595-3866
Practice Address - Street 1:12388 WARWICK BLVD STE 301E
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-3857
Practice Address - Country:US
Practice Address - Phone:757-595-3334
Practice Address - Fax:757-595-3866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA8821782008251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0103954456Medicaid