MEDICARE: MR. PETER CHRIS HOME MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCS15529	CA

General Provider Information

NPI Number	:	1134207699
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PETER CHRIS HOME MSW

Provider Business Mailing Address
First Line	:	769 W BLAINE ST
Second Line	:	SUITE A
City	:	RIVERSIDE
State	:	CA
Zip	:	92507-3970
Country	:	US
Telephone Number	:	951-358-6895
Fax Number	:	951-358-6176

Provider Business Practice Location Address
First Line	:	769 W BLAINE ST
Second Line	:	SUITE A
City	:	RIVERSIDE
State	:	CA
Zip	:	92507-3970
Country	:	US
Telephone Number	:	951-358-6895
Fax Number	:	951-358-6176

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/08/2007

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