Provider Demographics
NPI:1548514961
Name:RANCHO HAVEN CARE LLC
Entity type:Organization
Organization Name:RANCHO HAVEN CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GOPAL
Authorized Official - Middle Name:
Authorized Official - Last Name:SOJITRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-989-2899
Mailing Address - Street 1:9170 HAVEN AVE
Mailing Address - Street 2:STE 122
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5416
Mailing Address - Country:US
Mailing Address - Phone:909-989-2899
Mailing Address - Fax:909-945-5443
Practice Address - Street 1:9170 HAVEN AVE
Practice Address - Street 2:STE 122
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5416
Practice Address - Country:US
Practice Address - Phone:909-989-2899
Practice Address - Fax:909-945-5443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-07
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA519913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2151673OtherPK