=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083084123
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABOVE & BEYOND HOMECARE SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2015
-----------------------------------------------------
Last Update Date | 10/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35552 CORNELL DR
-----------------------------------------------------
City | YUCAIPA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92399-3932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-206-3104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35552 CORNELL DR
-----------------------------------------------------
City | YUCAIPA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92399-3932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-206-3104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER/HHA
-----------------------------------------------------
Name | CARRIE ANN CORNELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-206-3104
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | 12796
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------