Provider Demographics
NPI:1194750588
Name:FAJARDO HOME CARE PROGRAM, INC.
Entity type:Organization
Organization Name:FAJARDO HOME CARE PROGRAM, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:DRPH
Authorized Official - Phone:817-310-1100
Mailing Address - Street 1:1110 N CARROLL AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-5306
Mailing Address - Country:US
Mailing Address - Phone:817-310-1100
Mailing Address - Fax:817-310-1197
Practice Address - Street 1:375 AVE GENERAL VALERO
Practice Address - Street 2:SUITE 109
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738-4893
Practice Address - Country:US
Practice Address - Phone:787-868-6361
Practice Address - Fax:787-850-5270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11621251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR407019Medicare Oscar/Certification