Healthcare Provider Details

I. General information

NPI: 1003522996
Provider Name (Legal Business Name): MODERN CARE HOME HEALTH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16218 MIL POTRERO HWY UNIT 204 STE A
PINE MOUNTAIN CLUB CA
93222
US

IV. Provider business mailing address

16218 MIL POTRERO HWY UNIT 204 STE A
PINE MOUNTAIN CLUB CA
93222
US

V. Phone/Fax

Practice location:
  • Phone: 818-436-0153
  • Fax: 818-617-2849
Mailing address:
  • Phone: 818-436-0153
  • Fax: 818-617-2849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DAVID VARDAPETYAN
Title or Position: CEO,CFO,OWNER,SECRETARY
Credential:
Phone: 818-436-0153