Basic Information
| Provider Information | |||||||||
| NPI: | 1376879403 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AT HOME INFUSION SERVICES LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | KABAFUSION FL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 17777 CENTER COURT DR N | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | CERRITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907039320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004353020 | ||||||||
| FaxNumber: | 5626455396 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 NW 2ND AVE | ||||||||
| Address2: | SUITE 704 | ||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334315866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8773092207 | ||||||||
| FaxNumber: | 5613534666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2009 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RIGAS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF CLINICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8004353020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARM. D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0004X | N | Suppliers | Pharmacy | Compounding Pharmacy | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 3336H0001X | PH24426 | FL | Y | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 016895501 | 05 | FL | MEDICAID | 2122523 | 01 | PK | OTHER | 016895500 | 05 | FL | MEDICAID |