=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720265093
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AQUILA HEALTHCARE SYSTEMS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2008
-----------------------------------------------------
Last Update Date | 02/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3450 WILSHIRE BLVD SUITE 1000
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90010-2208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-380-1399
-----------------------------------------------------
Fax | 213-380-4046
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 CORPORATE POINTE STE 300-56
-----------------------------------------------------
City | CULVER CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90230-7615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-380-1399
-----------------------------------------------------
Fax | 213-380-4046
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. DAMON CLARK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 213-380-1399
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 980000772
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------