=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326207655
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE HOME CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2008
-----------------------------------------------------
Last Update Date | 12/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3807 SIERRA HWY SUITE #207
-----------------------------------------------------
City | ACTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93510-1255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-269-2279
-----------------------------------------------------
Fax | 661-269-2026
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3807 SIERRA HWY SUITE #207
-----------------------------------------------------
City | ACTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93510-1255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-794-3728
-----------------------------------------------------
Fax | 661-268-7693
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. TETYANA USTYNOVA
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 661-269-2279
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 550000624
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------