Provider Demographics
NPI:1053297366
Name:MEDHOME HEALTHCARE LLC
Entity type:Organization
Organization Name:MEDHOME HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KWAME
Authorized Official - Middle Name:
Authorized Official - Last Name:AGYEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-640-9517
Mailing Address - Street 1:25448 LAWTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3693
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1374 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5313
Practice Address - Country:US
Practice Address - Phone:840-444-7745
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty