Provider Demographics
NPI:1992369631
Name:PA HOME MODIFICATION
Entity type:Organization
Organization Name:PA HOME MODIFICATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-607-4400
Mailing Address - Street 1:3904 PERRYSVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15214-1748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3904 PERRYSVILLE AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15214-1748
Practice Address - Country:US
Practice Address - Phone:412-607-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherHOME ADAPTION