Provider Demographics
NPI:1104184761
Name:ANGELUS HOME HEALTH
Entity type:Organization
Organization Name:ANGELUS HOME HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MILES
Authorized Official - Middle Name:R
Authorized Official - Last Name:BALLESTEROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-999-0587
Mailing Address - Street 1:211 S LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-3833
Mailing Address - Country:US
Mailing Address - Phone:909-999-0587
Mailing Address - Fax:
Practice Address - Street 1:211 S LAUREL AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3833
Practice Address - Country:US
Practice Address - Phone:909-999-0587
Practice Address - Fax:909-781-2449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-01
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA059602Medicare Oscar/Certification