1124047386 NPI number — HELIOS HEALTHCARE, LLC

Table of content: (NPI 1124047386)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124047386 NPI number — HELIOS HEALTHCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HELIOS HEALTHCARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COUNTRY DRIVE CARE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124047386
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7590 SHORELINE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95219-5455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-955-2328
Provider Business Mailing Address Fax Number:
209-478-3717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 COUNTRY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREMONT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94536-5356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-792-4242
Provider Business Practice Location Address Fax Number:
510-792-4646
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLACKBURN
Authorized Official First Name:
LORI
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
209-955-2322

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 332BP3500X , with the licence number: 4935510007 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4935510007 . This is a "PART B SUPPLIER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZR05885I , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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