=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851069322
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CALVARY SENIOR CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2021
-----------------------------------------------------
Last Update Date | 08/31/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9650 BUSINESS CENTER DR # 110
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-4536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-317-4749
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9650 BUSINESS CENTER DR # 110
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-4536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-317-4749
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CARE COORDINATOR
-----------------------------------------------------
Name | TANDY J BROWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-559-2305
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------