=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679803522
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITAL CARE HOME HEALTH, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2009
-----------------------------------------------------
Last Update Date | 12/28/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2130 N ARROWHEAD AVE 103C
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92405-4023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-882-0101
-----------------------------------------------------
Fax | 909-882-0202
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2130 N ARROWHEAD AVE 103C
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92405-4023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-882-0101
-----------------------------------------------------
Fax | 909-882-0202
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR DESIGNEE
-----------------------------------------------------
Name | MRS. CARLA K. SULLIVAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-496-7710
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------