Provider Demographics
NPI:1902392095
Name:MEDSTAR HOME HEALTH, INC.
Entity Type:Organization
Organization Name:MEDSTAR HOME HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETROSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:818-424-1233
Mailing Address - Street 1:1927 W GLENOAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-1503
Mailing Address - Country:US
Mailing Address - Phone:818-967-5544
Mailing Address - Fax:818-967-5553
Practice Address - Street 1:1927 W GLENOAKS BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-1503
Practice Address - Country:US
Practice Address - Phone:818-967-5544
Practice Address - Fax:818-967-5553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGMedicaid