Provider Demographics
NPI:1134462294
Name:HISTORY MAKERS, INC
Entity Type:Organization
Organization Name:HISTORY MAKERS, INC
Other - Org Name:HOME HELPERS # 58362
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:FRANCES
Authorized Official - Last Name:BROOKERGARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:541-229-5263
Mailing Address - Street 1:220 CINBAR DR
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-9385
Mailing Address - Country:US
Mailing Address - Phone:541-229-5263
Mailing Address - Fax:541-229-5265
Practice Address - Street 1:220 CINBAR DR
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-9385
Practice Address - Country:US
Practice Address - Phone:541-229-5263
Practice Address - Fax:541-229-5265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15-2204253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR521319Medicaid