Provider Demographics
NPI:1134765050
Name:NORTHEASTERN HOME CARE SERVICES LLC
Entity type:Organization
Organization Name:NORTHEASTERN HOME CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-359-2436
Mailing Address - Street 1:72 EDWARDS DR STE 3
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-8783
Mailing Address - Country:US
Mailing Address - Phone:570-359-2436
Mailing Address - Fax:570-507-8452
Practice Address - Street 1:72 EDWARDS DR STE 3
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-8783
Practice Address - Country:US
Practice Address - Phone:570-359-2436
Practice Address - Fax:570-507-8452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031112580001Medicaid