Provider Demographics
NPI:1871575928
Name:MAXQUINDOM INC
Entity type:Organization
Organization Name:MAXQUINDOM INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PATIENT CARE SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:818-550-8268
Mailing Address - Street 1:730 S CENTRAL AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2061
Mailing Address - Country:US
Mailing Address - Phone:818-550-8268
Mailing Address - Fax:
Practice Address - Street 1:730 S CENTRAL AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2061
Practice Address - Country:US
Practice Address - Phone:818-550-8268
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHHA57600GMedicaid
CAHHA57600GMedicaid