Provider Demographics
NPI:1003573304
Name:AVICENNA HOME CARE AGENCY LLC
Entity Type:Organization
Organization Name:AVICENNA HOME CARE AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABDOULLAH
Authorized Official - Middle Name:
Authorized Official - Last Name:KABBAJ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-319-7475
Mailing Address - Street 1:8273 WHITE OAK AVE STE P
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-7671
Mailing Address - Country:US
Mailing Address - Phone:909-329-2699
Mailing Address - Fax:
Practice Address - Street 1:8273 WHITE OAK AVE STE P
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7671
Practice Address - Country:US
Practice Address - Phone:909-329-2699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-21
Last Update Date:2021-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA364700107OtherCDSS - HOME CARE SERVICES BUREAU