Provider Demographics
NPI:1063993673
Name:GOLDEN STATE HOME HEALTH, LLC
Entity type:Organization
Organization Name:GOLDEN STATE HOME HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROMAN
Authorized Official - Middle Name:RAMISCAL
Authorized Official - Last Name:DANNUG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD IN MANAGEMENT
Authorized Official - Phone:510-925-5543
Mailing Address - Street 1:22527 MAIN ST STE 206
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-4134
Mailing Address - Country:US
Mailing Address - Phone:510-606-9902
Mailing Address - Fax:510-454-8520
Practice Address - Street 1:22527 MAIN ST STE 206
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-4134
Practice Address - Country:US
Practice Address - Phone:510-606-9902
Practice Address - Fax:510-454-8520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550001972163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1073881819Medicaid