Provider Demographics
NPI:1326202904
Name:IBOLIT HOME HEALTH, INC
Entity Type:Organization
Organization Name:IBOLIT HOME HEALTH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GEORGIY
Authorized Official - Middle Name:
Authorized Official - Last Name:KASPAROV
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:818-557-7460
Mailing Address - Street 1:16461 SHERMAN WAY
Mailing Address - Street 2:SUITE 225
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-3842
Mailing Address - Country:US
Mailing Address - Phone:818-901-7770
Mailing Address - Fax:818-901-7772
Practice Address - Street 1:16461 SHERMAN WAY
Practice Address - Street 2:SUITE 225
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-3842
Practice Address - Country:US
Practice Address - Phone:818-901-7770
Practice Address - Fax:818-901-7772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-14
Last Update Date:2010-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550001063251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHHA09233FMedicaid
CAHHA09233FMedicaid