Provider Demographics
NPI:1558321901
Name:PROFESSIONAL HEALTHCARE AT HOME LLC
Entity Type:Organization
Organization Name:PROFESSIONAL HEALTHCARE AT HOME LLC
Other - Org Name:CENTERWELL HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED SIGNATORY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-246-6000
Mailing Address - Street 1:6330 SPRINT PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1157
Mailing Address - Country:US
Mailing Address - Phone:913-814-2674
Mailing Address - Fax:
Practice Address - Street 1:395 TAYLOR BLVD
Practice Address - Street 2:SUITE 118
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-2286
Practice Address - Country:US
Practice Address - Phone:925-246-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA020000449251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHHA07449FOtherMEDICAID
057449Medicare Oscar/Certification