Provider Demographics
NPI:1386141661
Name:EDIRA FAMILY HOME CARE LLC
Entity type:Organization
Organization Name:EDIRA FAMILY HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KORNEYEVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-293-5250
Mailing Address - Street 1:EDIRA FAMILY HOME CARE LLC
Mailing Address - Street 2:63-52 108 STREET LOWER LEVEL
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375
Mailing Address - Country:US
Mailing Address - Phone:917-293-5250
Mailing Address - Fax:718-830-6211
Practice Address - Street 1:EDIRA FAMILY HOME CARE LLC
Practice Address - Street 2:63-52 108 STREET LOWER LEVEL
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375
Practice Address - Country:US
Practice Address - Phone:917-293-5250
Practice Address - Fax:718-830-6211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2546L001251J00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2546L001OtherHOME CARE SERVICE AGENCY LICENSE