Basic Information
| Provider Information | |||||||||
| NPI: | 1336254192 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOMECARE REHAB, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 626 TRAIL AVE | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217014934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016621997 | ||||||||
| FaxNumber: | 3016682202 | ||||||||
| Practice Location | |||||||||
| Address1: | 626 TRAIL AVE | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217014934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016621997 | ||||||||
| FaxNumber: | 3016682202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BAKER | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3016621997 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | X | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | X | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235500000X | X | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Specialist/Technologist |
ID Information
| ID | Type | State | Issuer | Description | KBC4H0 | 01 | MD | MARYLAND BC/BS | OTHER | S404 | 01 | MD | CAREFIRST, BCBS | OTHER |