=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275929804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHY HEART HOME CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2015
-----------------------------------------------------
Last Update Date | 04/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15901 HAWTHORNE BL STE. 410
-----------------------------------------------------
City | LAWNDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-542-5555
-----------------------------------------------------
Fax | 310-542-4555
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15901 HAWTHORNE BL STE. 410
-----------------------------------------------------
City | LAWNDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-542-5555
-----------------------------------------------------
Fax | 310-542-4555
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DPCS
-----------------------------------------------------
Name | MS. KELLI FONVERGNE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-542-5555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------