1104136548 NPI number — AMARA HOME HEALTH, LLC

Table of content: (NPI 1104136548)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104136548 NPI number — AMARA HOME HEALTH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
AMARA HOME HEALTH, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104136548
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
175 N JACKSON AVE STE 103A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95116-1912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-258-5803
Provider Business Mailing Address Fax Number:
408-258-5830

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 N JACKSON AVE
Provider Second Line Business Practice Location Address:
SUITE 103-A
Provider Business Practice Location Address City Name:
SAN JOSE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95116-1909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-258-5803
Provider Business Practice Location Address Fax Number:
408-258-5830
Provider Enumeration Date:
10/19/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SUOR
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
619-453-5994

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  070000304 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: HHA57441F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".