=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003573304
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVICENNA HOME CARE AGENCY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2021
-----------------------------------------------------
Last Update Date | 11/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8273 WHITE OAK AVE STE P
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-7671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-329-2699
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8273 WHITE OAK AVE STE P
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-7671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-329-2699
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ABDOULLAH KABBAJ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-319-7475
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------