=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912347584
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MGM HOME HEALTHCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2013
-----------------------------------------------------
Last Update Date | 06/27/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1630 CONTRA COSTA BLVD SUITE 215
-----------------------------------------------------
City | PLEASANT HILL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94523-3085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-429-8320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1630 CONTRA COSTA BLVD SUITE 215
-----------------------------------------------------
City | PLEASANT HILL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94523-3085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-429-8320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | MICHAEL MENDAROS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 925-429-8320
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------