MEDICARE: PEPPERMINT HOLDINGS LLC

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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1205182714
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEPPERMINT HOLDINGS LLC

Provider Business Mailing Address
First Line	:	3350 SHELBY ST
Second Line	:	SUITE 370
City	:	ONTARIO
State	:	CA
Zip	:	91764-4882
Country	:	US
Telephone Number	:	909-784-3600
Fax Number	:	909-643-8059

Provider Business Practice Location Address
First Line	:	3350 SHELBY ST
Second Line	:	SUITE 370
City	:	ONTARIO
State	:	CA
Zip	:	91764-4882
Country	:	US
Telephone Number	:	909-784-3600
Fax Number	:	909-643-8059

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	TRAVIS WILSON
Credential	:
Telephone Number	:	909-784-3600

Provider Enumeration Date	:	08/02/2012
Last Update Date	:	08/10/2015

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