- Enrollment id
- O20190812000018
- Enrollment state
- CA
- Provider type code
- 00-06
- Provider type text
- PART A PROVIDER - HOME HEALTH AGENCY
- Npi
- 1225520109
- Multiple npi flag
- N
- Ccn
- 757688
- Associate id
- 5294062485
- Organization name
- PROVIDA HOME HEALTH, INC.
- Incorporation date
- 2017-12-19
- Incorporation state
- CA
- Organization type structure
- CORPORATION
- Proprietary nonprofit
- P
- Address line 1
- 14545 VICTORY BLVD
- Address line 2
- STE 418
- City
- VAN NUYS
- State
- CA
- Zip code
- 914114182
- Practice location type
- HHA BRANCH