Provider Demographics
NPI:1881985232
Name:PROFESSIONAL HEALTH CARE PROVIDER
Entity type:Organization
Organization Name:PROFESSIONAL HEALTH CARE PROVIDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSITA
Authorized Official - Middle Name:CRUZ
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:909-860-3080
Mailing Address - Street 1:406 S PROSPECTORS RD
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1659
Mailing Address - Country:US
Mailing Address - Phone:909-860-3080
Mailing Address - Fax:909-860-3008
Practice Address - Street 1:406 S PROSPECTORS RD
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-1659
Practice Address - Country:US
Practice Address - Phone:909-860-3080
Practice Address - Fax:909-860-3008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA980001445251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health