=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619109048
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FALLBROOK HOME CARE SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2009
-----------------------------------------------------
Last Update Date | 01/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 521 E ELDER ST SUITE 208
-----------------------------------------------------
City | FALLBROOK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92028-3004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-728-1191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 521 E ELDER ST SUITE 208
-----------------------------------------------------
City | FALLBROOK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92028-3004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-728-1191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, BUSINESS OFFICE SUPPORT
-----------------------------------------------------
Name | LAURIE HOLTSFORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-465-7466
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------