Healthcare Provider Details

I. General information

NPI: 1790378784
Provider Name (Legal Business Name): PROVIDE HOME HEALTH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2021
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 N LA BREA AVE FL 5
WEST HOLLYWOOD CA
90038-3161
US

IV. Provider business mailing address

925 N LA BREA AVE FL 5
WEST HOLLYWOOD CA
90038-3161
US

V. Phone/Fax

Practice location:
  • Phone: 310-383-7760
  • Fax: 310-405-0808
Mailing address:
  • Phone: 310-383-7760
  • Fax: 310-405-0808

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: QUERUBIN IGNACIO
Title or Position: CEO
Credential:
Phone: 310-383-7760