MEDICARE: PRINCIPAL HOME HEALTH 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		CA

General Provider Information

NPI Number	:	1912232620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRINCIPAL HOME HEALTH LLC

Provider Business Mailing Address
First Line	:	1021 N. CRESCENT HEIGHTS BLVD #207
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90046
Country	:	US
Telephone Number	:	310-775-1763
Fax Number	:

Provider Business Practice Location Address
First Line	:	1021 N. CRESCENT HEIGHTS BLVD #207
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90046
Country	:	US
Telephone Number	:	310-775-1763
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ADAM TRUNG-TAI PHAN
Credential	:	MBA
Telephone Number	:	310-775-1763

Provider Enumeration Date	:	10/14/2009
Last Update Date	:	10/14/2009

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