Provider Demographics
NPI:1104500123
Name:PAN HOMEHEALTH SUPPORT SERVICES LLC
Entity type:Organization
Organization Name:PAN HOMEHEALTH SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CLETUS
Authorized Official - Middle Name:A
Authorized Official - Last Name:FONMEDIG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-437-7749
Mailing Address - Street 1:4201 JOHN MARR DR STE 210
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-3204
Mailing Address - Country:US
Mailing Address - Phone:301-437-7749
Mailing Address - Fax:
Practice Address - Street 1:4201 JOHN MARR DR STE 210
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-3204
Practice Address - Country:US
Practice Address - Phone:301-437-7749
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities