=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013530112
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANTELOPE VALLEY HOME HEALTH AGENCY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2020
-----------------------------------------------------
Last Update Date | 05/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 445 W PALMDALE BLVD STE L
-----------------------------------------------------
City | PALMDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93551-4509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-407-2520
-----------------------------------------------------
Fax | 661-480-5090
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 445 W PALMDALE BLVD STE L
-----------------------------------------------------
City | PALMDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93551-4509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-407-2520
-----------------------------------------------------
Fax | 661-480-5090
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. JANNA PONOMARENKO
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 661-407-2520
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------