Provider Demographics
NPI:1811956394
Name:LA HOMECARE PROVIDER INC
Entity type:Organization
Organization Name:LA HOMECARE PROVIDER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRES/ ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:909-599-0777
Mailing Address - Street 1:1117 VIA VERDE
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-4400
Mailing Address - Country:US
Mailing Address - Phone:909-599-0777
Mailing Address - Fax:909-599-0711
Practice Address - Street 1:1117 VIA VERDE
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-4400
Practice Address - Country:US
Practice Address - Phone:909-599-0777
Practice Address - Fax:909-599-0711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA980001434163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
058186Medicare ID - Type Unspecified