=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942551767
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOOD LIFE HOME CARE OF CALIFORNIA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2012
-----------------------------------------------------
Last Update Date | 01/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1320 WILLOW PASS RD SUITE 460
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94520-5232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-915-6255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1320 WILLOW PASS RD SUITE 460
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94520-5232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR/COO
-----------------------------------------------------
Name | MR. MATTHEW BOWERSOX
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 831-915-6255
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------