Provider Demographics
NPI:1437484409
Name:ST. MARY HIGH DESERT HOME HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:ST. MARY HIGH DESERT HOME HEALTH SERVICES, LLC
Other - Org Name:PROVIDENCE HOME HEALTH HIGH DESERT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY FOR ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:17081 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-6075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17051 MAIN ST
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-6055
Practice Address - Country:US
Practice Address - Phone:909-984-0400
Practice Address - Fax:909-984-4700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-08
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health