Healthcare Provider Details

I. General information

NPI: 1790734036
Provider Name (Legal Business Name): CORAM ALTERNATE SITE SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 03/07/2023
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12310 WORLD TRADE DR SUITE 100
SAN DIEGO CA
92128-3793
US

IV. Provider business mailing address

PO BOX 809160
CHICAGO IL
60680-9160
US

V. Phone/Fax

Practice location:
  • Phone: 858-576-6969
  • Fax: 858-974-6606
Mailing address:
  • Phone: 480-765-5043
  • Fax: 401-733-0211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number0800429
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number0800429
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberPHY50273
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License NumberPHY50273
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY50273
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY50273
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPHY50273
License Number StateCA
# 9
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License NumberPHY50273
License Number StateCA
# 10
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License NumberPHY50273
License Number StateCA
# 11
Primary TaxonomyY
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License NumberPHY50273
License Number StateCA

VIII. Authorized Official

Name: TRICIA LACAVICH
Title or Position: PRESIDENT
Credential:
Phone: 314-306-3255