Healthcare Provider Details

I. General information

NPI: 1730514555
Provider Name (Legal Business Name): AT HOME CARE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2013
Last Update Date: 09/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 SE WILSON AVE
BEND OR
97702-1799
US

IV. Provider business mailing address

205 SE WILSON AVE
BEND OR
97702-1799
US

V. Phone/Fax

Practice location:
  • Phone: 541-312-0051
  • Fax: 541-312-0077
Mailing address:
  • Phone: 541-312-0051
  • Fax: 541-312-0077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number15-2220
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. KEVIN COX
Title or Position: MEMBER
Credential:
Phone: 541-312-0051