Provider Demographics
NPI:1497813349
Name:PROFOUND HEALTH CARE
Entity Type:Organization
Organization Name:PROFOUND HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NIBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-294-3559
Mailing Address - Street 1:4078 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-2515
Mailing Address - Country:US
Mailing Address - Phone:323-294-3559
Mailing Address - Fax:323-294-3362
Practice Address - Street 1:4078 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-2515
Practice Address - Country:US
Practice Address - Phone:323-294-3559
Practice Address - Fax:323-294-3362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHHA08024FMedicaid
CA058024Medicare ID - Type UnspecifiedHHA