Active NPI
360 Home Health Agency
- Home Health Agency
- Canoga Park, CA
National Provider Identifier
1104220623
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Home Health Agency
- Legal business name
- 360 HOME HEALTH AGENCY
- Practice address
- 21133 Victory Blvd
Suite 206
Canoga Park, CA 91303-2829 - Phone
- (818) 888-0100
- NPI assigned
- Oct 13, 2014
- Last updated
- Dec 14, 2014
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Rafayel Nersisyan, RN
- Title
- President
- Phone
- (818) 888-0100
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Home Health Agency | 251E00000X | CA | Primary |
Addresses
Primary practice location
21133 Victory Blvd
Suite 206
Canoga Park, CA 91303-2829
Mailing address
20741 Dolorosa St
Woodland Hills, CA 91367-6837
Phone (818) 888-0100
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20141205000691 | CA | Part A Provider - Home Health Agency | 9032431820 | Practice locations: Canoga Park, CA |
NPI to CCN mapping 1
The Medicare certification numbers (CCNs) connected to NPI 1104220623. Details of each certification follow.
Home health agency certification: CCN 059742
- Legal name
- 360 HOME HEALTH AGENCY
- Certification status
- Active
- Provider type (POS)
- Home health agency
- Participating since
- Aug 17, 2016
- Last certification
- May 31, 2019
- Ownership / control type
- Proprietary
- Organization structure
- Corporation
- Incorporated
- Sep 8, 2014 in CA
- Enrollment address
- 21133 Victory Blvd 206
Canoga Park, CA 91303-4018
Care Compare: Home health agency
Medicare Care Compare- Listed as
- 360 Home Health Agency
- Overall star rating
- Ownership
- Proprietary
- Certified
- Aug 17, 2016
- Medicare certification status
- Active
- Services
- Nursing, Medical social, Home health aide, Physical therapy, Speech pathology, Occupational therapy
Laboratory certificates & supplier records
Derived by NPIMapThese CMS records do not include an NPI. They are shown because their name and street address match this provider’s.
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 05D2098037 | 360 Home Health Agency | Certificate of waiver | Jun 28, 2027 |
National Provider Directory
National Provider DirectoryLocations
21101 Victory Blvd
#206
Canoga Park, CA 91303
Phone (818) 888-0100
21133 Victory Blvd
Ste 206
Canoga Park, CA 91303
Phone (818) 888-0100
Ownership & related parties
All disclosed owners & managing parties 2
As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.
| Name | Role | Since | Share |
|---|---|---|---|
| Rafayel Nersisyan | 5% Or Greater Direct Ownership Interest | Sep 18, 2014 | 50% |
| W-2 Managing Employee | Sep 18, 2014 | ||
| Alexander Lyubenkov | 5% Or Greater Direct Ownership Interest | Sep 8, 2014 | 50% |
Practitioners & affiliated clinicians
Affiliated clinicians 9
Clinicians who list this facility as an affiliation in Medicare Care Compare.
-
- Internal Medicine Physician
- Los Angeles, CA
- NPI 1467480137
Home health agency
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1413158400000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1418515200000",
"number": "1104220623",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "20741 DOLOROSA ST",
"city": "WOODLAND HILLS",
"state": "CA",
"postal_code": "913676837",
"telephone_number": "818-888-0100"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "21133 VICTORY BLVD",
"address_2": "SUITE 206",
"city": "CANOGA PARK",
"state": "CA",
"postal_code": "913032829",
"telephone_number": "818-888-0100"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "360 HOME HEALTH AGENCY",
"organizational_subpart": "NO",
"enumeration_date": "2014-10-13",
"last_updated": "2014-12-14",
"status": "A",
"authorized_official_last_name": "NERSISYAN",
"authorized_official_first_name": "RAFAYEL",
"authorized_official_title_or_position": "PRESIDENT",
"authorized_official_telephone_number": "818-888-0100",
"authorized_official_credential": "RN"
},
"taxonomies": [
{
"code": "251E00000X",
"taxonomy_group": "",
"desc": "Home Health",
"state": "CA",
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Canoga Park, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 14, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.