=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831246032
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. BERNARDINE CARE PROVIDERS,INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2007
-----------------------------------------------------
Last Update Date | 11/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18064 WIKA RD STE 202
-----------------------------------------------------
City | APPLE VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92307-2182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-242-6720
-----------------------------------------------------
Fax | 760-242-6731
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 VENTURE STE 375
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-7367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-397-6091
-----------------------------------------------------
Fax | 949-629-4179
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MR. MASOUD SHOJAEI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-397-6091
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------