Organization
IMMACULATE MARY HOME
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MICHAEL CZEKNER (CHIEF FINANCIAL OFFICER)
(215) 368-0900
Entity
Organization
Contact information
Practice address
2990 HOLME AVE, PHILADELPHIA, PA 19136-1830
(215) 335-2100
(215) 368-5254
Mailing address
2990 HOLME AVE, PHILADELPHIA, PA 19136-1830
(215) 335-2100
(215) 368-5254
Taxonomy
Speciality
Code
Description
License number
State
332BP3500X
Parenteral & Enteral Nutrition Supplies (DME)
Primary
090902
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0649990001
NSC DME SUPPLIER NO
—
Enumeration date
11/29/2006
Last updated
08/22/2020
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