Provider Demographics
NPI:1518099167
Name:PROFESSIONAL HOME CARE
Entity Type:Organization
Organization Name:PROFESSIONAL HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-342-8302
Mailing Address - Street 1:3318 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-1592
Mailing Address - Country:US
Mailing Address - Phone:541-342-8302
Mailing Address - Fax:541-342-3876
Practice Address - Street 1:3318 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-1592
Practice Address - Country:US
Practice Address - Phone:541-342-8302
Practice Address - Fax:541-342-3876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15-2069251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR702946Medicaid