Basic Information
Provider Information | |||||||||
NPI: | 1730250689 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HOME NURSING AGENCY COMMUNITY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 201 CHESTNUT AVE | ||||||||
Address2: | PRIVATE DUTY | ||||||||
City: | ALTOONA | ||||||||
State: | PA | ||||||||
PostalCode: | 166014927 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8149465411 | ||||||||
FaxNumber: | 8149421673 | ||||||||
Practice Location | |||||||||
Address1: | 1216 PLEASANT VALLEY BOULEVARD | ||||||||
Address2: | SUITE 208 - PRIVATE DUTY | ||||||||
City: | ALTOONA | ||||||||
State: | PA | ||||||||
PostalCode: | 166024750 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8149465411 | ||||||||
FaxNumber: | 8149408471 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/13/2006 | ||||||||
LastUpdateDate: | 04/24/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FREEMAN | ||||||||
AuthorizedOfficialFirstName: | PHILIP | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8149465411 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X | 15283601 | PA | Y |   | Agencies | In Home Supportive Care |   |
ID Information
ID | Type | State | Issuer | Description | 1000007650039 | 05 | PA |   | MEDICAID |