Provider Demographics
NPI:1003055195
Name:CUSTOMCARE HOME HEALTH SERVICES INC.
Entity Type:Organization
Organization Name:CUSTOMCARE HOME HEALTH SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:916-714-1155
Mailing Address - Street 1:PO BOX 2792
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95759-2792
Mailing Address - Country:US
Mailing Address - Phone:916-714-1155
Mailing Address - Fax:916-714-1165
Practice Address - Street 1:8837 ELK GROVE BLVD STE AANDB
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-1828
Practice Address - Country:US
Practice Address - Phone:916-714-1155
Practice Address - Fax:916-405-3434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100000543251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1003055195Medicaid
CA1003055195Medicaid
CA05-9666Medicare PIN