Provider Demographics
NPI:1700813615
Name:CENTERWELL CERTIFIED HEALTHCARE CORP
Entity Type:Organization
Organization Name:CENTERWELL CERTIFIED HEALTHCARE CORP
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:707-545-7114
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:
Mailing Address - Fax:
Practice Address - Street 1:5341 OLD REDWOOD HWY STE 350
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-7127
Practice Address - Country:US
Practice Address - Phone:707-545-7114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ34072ZOtherCA-BLUE SHIELD
05-7036OtherCA-COMMERCIAL NUMBER
010000084OtherCA-COMMERCIAL NUMBER
CA333724Medicaid
520121OtherCA-COMMERCIAL NUMBER
11-3414024OtherCA-COMMERCIAL NUMBER
564478OtherCA-COMMERCIAL NUMBER
5868461OtherCA-COMMERCIAL NUMBER
057036OtherCA-COMMERCIAL NUMBER
CAZZR07036HMedicaid
013100POtherCA-COMMERCIAL NUMBER
106825024OtherCA-COMMERCIAL NUMBER
113414024OtherCA-COMMERCIAL NUMBER
565800OtherCA-COMMERCIAL NUMBER
GA0699OtherCA-COMMERCIAL NUMBER
ZZZ34072ZOtherCA-BLUE SHIELD
010000084OtherCA-COMMERCIAL NUMBER