Provider Demographics
NPI:1962870238
Name:TRADITIONAL HOME CARE LLC
Entity type:Organization
Organization Name:TRADITIONAL HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED NURSE
Authorized Official - Prefix:
Authorized Official - First Name:DOREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:NIXON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:570-507-9420
Mailing Address - Street 1:113 W DRINKER ST
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18512-1913
Mailing Address - Country:US
Mailing Address - Phone:570-207-9286
Mailing Address - Fax:
Practice Address - Street 1:1439 MONROE AVE STE 6
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18509-2497
Practice Address - Country:US
Practice Address - Phone:570-507-9420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-03
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA28573601253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA28573601OtherPA DEPARMTNET OF HEALTH