Basic Information
Provider Information | |||||||||
NPI: | 1942312012 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MEDI HOME HEALTH AGENCY, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MEDI HOME HEALTH AGENCY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1928 | ||||||||
Address2: |   | ||||||||
City: | LEXINGTON | ||||||||
State: | SC | ||||||||
PostalCode: | 290711928 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8039570500 | ||||||||
FaxNumber: | 8883426190 | ||||||||
Practice Location | |||||||||
Address1: | 341 SCIENCE PARK RD | ||||||||
Address2: | STE 207 | ||||||||
City: | STATE COLLEGE | ||||||||
State: | PA | ||||||||
PostalCode: | 168032287 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8142351048 | ||||||||
FaxNumber: | 8142351367 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 04/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JEFFCOAT | ||||||||
AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8039570500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 02830501 | PA | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 102570022-0001 | 05 | PA |   | MEDICAID |