Provider Demographics
NPI:1871938373
Name:GREAT I AM WELFARE AND DEVELOPMENT HOME HEALTH AGENCY LLC
Entity type:Organization
Organization Name:GREAT I AM WELFARE AND DEVELOPMENT HOME HEALTH AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARROLL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:9093-292-0334
Mailing Address - Street 1:14189 FOOTHILL BLVD
Mailing Address - Street 2:102
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-3093
Mailing Address - Country:US
Mailing Address - Phone:909-329-3024
Mailing Address - Fax:
Practice Address - Street 1:14189 FOOTHILL BLVD
Practice Address - Street 2:102
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3093
Practice Address - Country:US
Practice Address - Phone:909-329-3024
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA201312310016251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health