Provider Demographics
NPI:1811976418
Name:PENINSULA HOME CARE, LLC
Entity type:Organization
Organization Name:PENINSULA HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEBUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-731-2403
Mailing Address - Street 1:2459 WILKINSON BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5669
Mailing Address - Country:US
Mailing Address - Phone:704-831-5059
Mailing Address - Fax:
Practice Address - Street 1:1001 MOUNT HERMON RD
Practice Address - Street 2:STE 200
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5107
Practice Address - Country:US
Practice Address - Phone:410-543-7550
Practice Address - Fax:410-543-7555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDHH7079251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD57348602OtherBCBS
734650OtherAETNA
734650OtherAETNA