Basic Information
Provider Information
NPI: 1720453442
EntityType: 2
ReplacementNPI:  
OrganizationName: HOME START
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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OtherCredential:  
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Mailing Information
Address1: 3003 E MAIN STREET
Address2:  
City: EL CAJON
State: CA
PostalCode: 92020
CountryCode: US
TelephoneNumber: 6196920727
FaxNumber: 6196920785
Practice Location
Address1: 131 AVOCADO AVE
Address2:  
City: EL CAJON
State: CA
PostalCode: 92020
CountryCode: US
TelephoneNumber: 6196920727
FaxNumber: 6196920785
Other Information
ProviderEnumerationDate: 12/07/2015
LastUpdateDate: 12/07/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: FENTON
AuthorizedOfficialFirstName: GERRIE
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: PROGRAM COORDINATOR
AuthorizedOfficialTelephone: 6193280954
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
251B00000X  Y AgenciesCase Management 

No ID Information.


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