Provider Demographics
NPI:1821633702
Name:PORTVILLE GROUP
Entity Type:Organization
Organization Name:PORTVILLE GROUP
Other - Org Name:PORTVILLE HOME CARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:YUSUFF
Authorized Official - Middle Name:OMOTAYO
Authorized Official - Last Name:KAZZIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-636-7944
Mailing Address - Street 1:5568 HANNIBAL CT
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80239-5696
Mailing Address - Country:US
Mailing Address - Phone:323-636-7944
Mailing Address - Fax:
Practice Address - Street 1:5568 HANNIBAL CT
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80239-5696
Practice Address - Country:US
Practice Address - Phone:323-636-7944
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PORTVILLE GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-14
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No253Z00000XAgenciesIn Home Supportive Care
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite Care