Provider Demographics
NPI:1982986360
Name:PEPPERMINT HOLDINGS LLC
Entity type:Organization
Organization Name:PEPPERMINT HOLDINGS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-784-3600
Mailing Address - Street 1:3350 SHELBY ST
Mailing Address - Street 2:SUITE 370
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-4882
Mailing Address - Country:US
Mailing Address - Phone:909-784-3600
Mailing Address - Fax:909-643-8059
Practice Address - Street 1:3350 SHELBY ST
Practice Address - Street 2:SUITE 370
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-4882
Practice Address - Country:US
Practice Address - Phone:909-784-3600
Practice Address - Fax:909-643-8059
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEPPERMINT HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-12
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA051773Medicare Oscar/Certification