Provider Demographics
NPI:1164194684
Name:ABBEY'S HOME, LLC.
Entity Type:Organization
Organization Name:ABBEY'S HOME, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NAZARETH
Authorized Official - Middle Name:
Authorized Official - Last Name:TESFASILASE
Authorized Official - Suffix:
Authorized Official - Credentials:RN,BSN
Authorized Official - Phone:909-782-6925
Mailing Address - Street 1:15554 ROCKWELL AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336
Mailing Address - Country:US
Mailing Address - Phone:909-782-6925
Mailing Address - Fax:
Practice Address - Street 1:15554 ROCKWELL AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336
Practice Address - Country:US
Practice Address - Phone:909-782-6925
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-03
Last Update Date:2021-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA201507210428OtherSECRETARY OF STATE