Provider Demographics
NPI:1669657821
Name:HEAVENLY HOME HEALTH CARE, INC.
Entity Type:Organization
Organization Name:HEAVENLY HOME HEALTH CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VARTAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DERMENDJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-662-7071
Mailing Address - Street 1:4430 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-2014
Mailing Address - Country:US
Mailing Address - Phone:323-662-7071
Mailing Address - Fax:323-662-0189
Practice Address - Street 1:3200 W BURBANK BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-2201
Practice Address - Country:US
Practice Address - Phone:323-662-7071
Practice Address - Fax:323-662-0189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000279251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA058452Medicare Oscar/Certification