Basic Information
| Provider Information | |||||||||
| NPI: | 1811402100 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROSPECT CHARTERCARE HOME HEALTH AND HOSPICE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 MAUDE ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029084325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014562273 | ||||||||
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| Practice Location | |||||||||
| Address1: | 50 MAUDE ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029084325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014562273 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2017 | ||||||||
| LastUpdateDate: | 04/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | ELDERS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 7147881249 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | ESQ. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WH0200X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Home Health | 251G00000X | N | Agencies | Hospice Care, Community Based | 251E00000X | Y | Agencies | Home Health |
No ID Information.