=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689044745
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIVE CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2015
-----------------------------------------------------
Last Update Date | 08/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19500 NORMANDIE AVE STE B
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-974-4080
-----------------------------------------------------
Fax | 877-742-0658
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19500 NORMANDIE AVE STE B
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90502-1108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-974-4080
-----------------------------------------------------
Fax | 877-742-0658
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DMITRY UCHITEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-974-4080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 550003235
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------