Basic Information
| Provider Information | |||||||||
| NPI: | 1841219011 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HELIOS HEALTHCARE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | EL CAMINO CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7590 SHORELINE DR | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952195455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099552328 | ||||||||
| FaxNumber: | 2094783717 | ||||||||
| Practice Location | |||||||||
| Address1: | 2540 CARMICHAEL WAY | ||||||||
| Address2: | |||||||||
| City: | CARMICHAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956085314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164820465 | ||||||||
| FaxNumber: | 9164827813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BLACKBURN | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2099552322 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | X | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 332BP3500X | 4935510006 | CA | X | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition |
ID Information
| ID | Type | State | Issuer | Description | ZZR05402I | 05 | CA | MEDICAID | 4935510006 | 01 | CA | PART B SUPPLIER | OTHER |