Provider Demographics
NPI:1801121769
Name:AVISTA HOME HEALTHCARE LLC
Entity type:Organization
Organization Name:AVISTA HOME HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:AVIS
Authorized Official - Middle Name:HANY
Authorized Official - Last Name:CHOULAGH
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:586-405-0341
Mailing Address - Street 1:5237 OAKMAN BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-4045
Mailing Address - Country:US
Mailing Address - Phone:586-405-0341
Mailing Address - Fax:
Practice Address - Street 1:5237 OAKMAN BLVD STE D
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4045
Practice Address - Country:US
Practice Address - Phone:586-405-0341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-11
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health