Provider Demographics
NPI:1962474387
Name:WESTERN STATES HOMEHEALTH CARE AGENCY INC
Entity Type:Organization
Organization Name:WESTERN STATES HOMEHEALTH CARE AGENCY INC
Other - Org Name:WESTERN STATE HOME HEALTH CARE,INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/ C.F.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:EPHREM
Authorized Official - Middle Name:
Authorized Official - Last Name:TILAHUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-672-4581
Mailing Address - Street 1:5777 W CENTURY BLVD STE 610
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5600
Mailing Address - Country:US
Mailing Address - Phone:310-672-4581
Mailing Address - Fax:310-672-6586
Practice Address - Street 1:5777 W CENTURY BLVD STE 610
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-5600
Practice Address - Country:US
Practice Address - Phone:310-672-4581
Practice Address - Fax:310-672-6586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA980001323251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHHA08097FMedicaid
ZZZ06223ZOtherBLUE SHIELD
CAHHA08097FMedicaid