- Enrollment id
- O20201215001734
- Enrollment state
- CA
- Provider type code
- 00-06
- Provider type text
- PART A PROVIDER - HOME HEALTH AGENCY
- Npi
- 1255821070
- Multiple npi flag
- N
- Ccn
- 559547
- Associate id
- 5799197836
- Organization name
- FORMEN & FORMEN HOME HEALTH INC
- Incorporation date
- 2018-02-23
- Incorporation state
- CA
- Organization type structure
- CORPORATION
- Proprietary nonprofit
- P
- Address line 1
- 664 W BROADWAY
- Address line 2
- UNIT H
- City
- GLENDALE
- State
- CA
- Zip code
- 912041008