Provider Demographics
NPI:1548393978
Name:PROVIDENCE HOME HEALTH CARE, INC
Entity Type:Organization
Organization Name:PROVIDENCE HOME HEALTH CARE, INC
Other - Org Name:PROVIDENCE HOME HEALTH CARE, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MANOUSHAK
Authorized Official - Middle Name:
Authorized Official - Last Name:AKHOYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-792-0911
Mailing Address - Street 1:424 N LAKE AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1200
Mailing Address - Country:US
Mailing Address - Phone:626-792-0911
Mailing Address - Fax:626-792-8911
Practice Address - Street 1:424 N LAKE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1200
Practice Address - Country:US
Practice Address - Phone:626-792-0911
Practice Address - Fax:626-792-8911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA980001498251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHH08218FMedicaid
CAHH08218FMedicaid