=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366720898
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE ISLAND HOME CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2011
-----------------------------------------------------
Last Update Date | 08/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4979 SAN RAFAEL AVE
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89120-1634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-269-4918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 12031
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89112-0031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | NELA ACUNA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-300-9053
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | NV20091365394
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------