=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508272360
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHY LIVING AT HOME - EL CENTRO, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2014
-----------------------------------------------------
Last Update Date | 09/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 502 W ATEN RD SUITE 104
-----------------------------------------------------
City | IMPERIAL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92251-9423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-545-0330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 502 W ATEN RD SUITE 104
-----------------------------------------------------
City | IMPERIAL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92251-9423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-545-0330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | JASON BLISS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 760-545-0330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------