Provider Demographics
NPI:1275587685
Name:ADVANCED HOME MEDICAL INC
Entity Type:Organization
Organization Name:ADVANCED HOME MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANGAER
Authorized Official - Prefix:MRS
Authorized Official - First Name:YEA
Authorized Official - Middle Name:
Authorized Official - Last Name:REAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-444-2991
Mailing Address - Street 1:23785 CANYON VISTA CT
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-6116
Mailing Address - Country:US
Mailing Address - Phone:909-861-4871
Mailing Address - Fax:909-444-5503
Practice Address - Street 1:312 PASEO TESORO
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-2725
Practice Address - Country:US
Practice Address - Phone:909-444-2991
Practice Address - Fax:909-444-5503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332B00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME02989GMedicaid
WA9052838Medicaid
UT1275587685Medicaid
KY9000633900Medicaid
IN200282740AMedicaid
MI874736565Medicaid
KY90006339Medicaid
KY90006339Medicaid
UT1275587685Medicaid