=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437745197
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERGO HOME HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2020
-----------------------------------------------------
Last Update Date | 12/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5657 WILSHIRE BLVD STE 430
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90036-3741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-483-5027
-----------------------------------------------------
Fax | 323-483-5072
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5657 WILSHIRE BLVD STE 430
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90036-3741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-483-5027
-----------------------------------------------------
Fax | 323-483-5072
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, CEO, CFO, SECRETARY
-----------------------------------------------------
Name | MS. BRITTANY PENA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-483-5027
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------