Provider Demographics
NPI:1265795454
Name:SALEM HOME CARE AGENCY, LLC
Entity type:Organization
Organization Name:SALEM HOME CARE AGENCY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAVE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:347-471-4707
Mailing Address - Street 1:220 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-2517
Mailing Address - Country:US
Mailing Address - Phone:516-451-9426
Mailing Address - Fax:516-887-1991
Practice Address - Street 1:220 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-2517
Practice Address - Country:US
Practice Address - Phone:516-476-1475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SALEM HOME CARE AGENCY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120124000198311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility