Basic Information
Provider Information | |||||||||
NPI: | 1730422619 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PTV1, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HOME HEALTH CARE SPECIALISTS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 160 E HORIZON DR | ||||||||
Address2: | SUITE A | ||||||||
City: | HENDERSON | ||||||||
State: | NV | ||||||||
PostalCode: | 890157933 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 160 E HORIZON DR | ||||||||
Address2: | SUITE A | ||||||||
City: | HENDERSON | ||||||||
State: | NV | ||||||||
PostalCode: | 890157933 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7026443600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2013 | ||||||||
LastUpdateDate: | 01/02/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JIMENEZ | ||||||||
AuthorizedOfficialFirstName: | EDGAR | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR/OWNER | ||||||||
AuthorizedOfficialTelephone: | 7022736658 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X |   |   | Y |   | Agencies | In Home Supportive Care |   |
ID Information
ID | Type | State | Issuer | Description | 9005039969 | 05 | NV |   | MEDICAID |