Provider Demographics
| NPI: | 1962890053 |
|---|---|
| Name: | HERO'S SHELTER INC. |
| Entity type: | Organization |
| Organization Name: | HERO'S SHELTER INC. |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | HEALTH SERVICES EXECUTIVE |
| Authorized Official - Prefix: | MS |
| Authorized Official - First Name: | OLUWAPELUMI |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | OLUKOTUN |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | BSN, MSHA, APRN, CCM |
| Authorized Official - Phone: | 571-400-8461 |
| Mailing Address - Street 1: | PO BOX 558 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | SAN LUIS REY |
| Mailing Address - State: | CA |
| Mailing Address - Zip Code: | 92068-0558 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 571-400-8461 |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 3646 OCEAN RANCH BLVD |
| Practice Address - Street 2: | |
| Practice Address - City: | OCEANSIDE |
| Practice Address - State: | CA |
| Practice Address - Zip Code: | 92056-2669 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 571-400-8461 |
| Practice Address - Fax: | |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2014-12-26 |
| Last Update Date: | 2020-08-13 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 251B00000X, 251K00000X, 251S00000X, 251T00000X, 251V00000X, 253J00000X, 261QC1500X, 261QC1800X, 282J00000X, 332B00000X | ||
| CA | TCP24200P | 347C00000X |
| CA | 280514 | 251K00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 251K00000X | Agencies | Public Health or Welfare | |
| No | 251B00000X | Agencies | Case Management | |
| No | 251S00000X | Agencies | Community/Behavioral Health | |
| No | 251T00000X | Agencies | Program of All-Inclusive Care for the Elderly (PACE) Provider Organization | |
| No | 251V00000X | Agencies | Voluntary or Charitable | |
| No | 253J00000X | Agencies | Foster Care Agency | |
| No | 261QC1500X | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
| No | 261QC1800X | Ambulatory Health Care Facilities | Clinic/Center | Corporate Health |
| No | 282J00000X | Hospitals | Religious Nonmedical Health Care Institution | |
| No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | |
| No | 347C00000X | Transportation Services | Private Vehicle |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| FL | 999999999999 | Medicaid | |
| PR | 999999999999 | Medicaid | |
| WV | 999999999999 | Medicaid | |
| MN | 999999999999 | Medicaid | |
| AK | 999999999999 | Medicaid | |
| CO | 999999999999 | Medicaid | |
| AK | 99999999999999 | Medicaid | |
| NV | 999999999999 | Medicaid | |
| MD | 999999999999 | Medicaid | |
| AR | 999999999999 | Medicaid | |
| VA | 999999999999 | Medicaid | |
| NE | 999999999999 | Medicaid | |
| HI | 999999999999 | Medicaid | |
| MA | 999999999999 | Medicaid | |
| MO | 999999999999 | Medicaid | |
| NJ | 999999999999 | Medicaid | |
| OH | 999999999999 | Medicaid | |
| IN | 999999999999 | Medicaid | |
| CT | 999999999999 | Medicaid | |
| PA | 999999999999 | Medicaid | |
| AZ | 999999999999 | Medicaid | |
| TX | 999999999999 | Medicaid | |
| SC | 999999999999 | Medicaid | |
| CA | 999999999999 | Medicaid | |
| IL | 999999999999 | Medicaid | |
| DC | 999999999999 | Medicaid | |
| DE | 999999999999 | Medicaid | |
| TN | 999999999999 | Medicaid | |
| SD | 999999999999 | Medicaid | |
| NY | 999999999999 | Medicaid | |
| NC | 999999999999 | Medicaid | |
| VI | 9999999999999 | Medicaid |
