Basic Information
| Provider Information | |||||||||
| NPI: | 1164419990 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUILDING BLOCKS PEDIATRIC HOME HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 779 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292020779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138908004 | ||||||||
| FaxNumber: | 8132909691 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 JOURNEY | ||||||||
| Address2: | SUITES 135 | ||||||||
| City: | ALISO VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926565317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138908004 | ||||||||
| FaxNumber: | 8132909691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 05/19/2011 | ||||||||
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| AuthorizedOfficialLastName: | MILLS | ||||||||
| AuthorizedOfficialFirstName: | RON | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8138908004 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WH0200X | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Home Health |
ID Information
| ID | Type | State | Issuer | Description | HHA57464G | 05 | CA | MEDICAID |