Healthcare Provider Details

I. General information

NPI: 1205134442
Provider Name (Legal Business Name): IN-HOME NON-EMERGENCY TREATMENT TEAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2011
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17240 ENCINA DR
LAKE ELSINORE CA
92530-5744
US

IV. Provider business mailing address

17240 ENCINA DR
LAKE ELSINORE CA
92530-5744
US

V. Phone/Fax

Practice location:
  • Phone: 951-457-3315
  • Fax:
Mailing address:
  • Phone: 951-457-3315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNULL
# 10
Primary TaxonomyN
Taxonomy Code364SC2300X
TaxonomyChronic Care Clinical Nurse Specialist
License Number
License Number StateNULL
# 11
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 12
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number StateNULL
# 13
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 14
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 15
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. JEREMY D COOK
Title or Position: CEO
Credential:
Phone: 951-457-3315