Provider Demographics
NPI:1053961664
Name:AVITA HOME CARE LLC
Entity type:Organization
Organization Name:AVITA HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:PISTORIUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-334-4450
Mailing Address - Street 1:730 JAMAICA BLVD STE 24
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08757-3758
Mailing Address - Country:US
Mailing Address - Phone:732-202-6677
Mailing Address - Fax:732-719-3070
Practice Address - Street 1:950 TILTON RD STE 101
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08225-1235
Practice Address - Country:US
Practice Address - Phone:908-907-3135
Practice Address - Fax:732-719-3070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-16
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
No251E00000XAgenciesHome HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0721514Medicaid