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General NPI Number Information
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NPI Number | 1821410655
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Entity Type | Organization
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Legal Business Name | CUSTOM CARE COMPANION
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Dates
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Enumeration Date | 01/14/2014
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Last Update Date | 01/14/2014
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Provider Practice Location Address
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Address Line | 9826 BOND RD # B
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City | ELK GROVE
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State | CA
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Zip | 95624-9419
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Country | US
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Telephone | 916-704-3933
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Fax | 916-714-1165
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Provider Business Mailing Address
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Address Line | 2373 PO BOX
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City | ELK GROVE
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State | CA
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Zip | 95759
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Country | US
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Telephone | 916-714-1155
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Fax | 916-714-1165
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Authorized Official
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Title or Position | M
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Name | MISS KIESHA CHARLTON
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Credential |
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Telephone | 916-714-1155
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 1400015060
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License Number State | CA
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