Healthcare Provider Details

I. General information

NPI: 1740856251
Provider Name (Legal Business Name): GOOD LIFE HOME HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1264 S WATERMAN AVE STE 27
SAN BERNARDINO CA
92408-2848
US

IV. Provider business mailing address

1264 S WATERMAN AVE STE 27
SAN BERNARDINO CA
92408-2848
US

V. Phone/Fax

Practice location:
  • Phone: 909-332-7792
  • Fax: 909-494-7593
Mailing address:
  • Phone: 909-332-7792
  • Fax: 909-494-7593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State

VIII. Authorized Official

Name: LATESHA KING
Title or Position: CEO
Credential:
Phone: 909-332-7792