MEDICARE: MACKELLAH HOME

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311ZA0620X	Adult Care Home Facility	347000955	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	34DP	OTHER	CA	CARE HOME

General Provider Information

NPI Number	:	1043300320
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MACKELLAH HOME

Provider Business Mailing Address
First Line	:	6813 MARINVALE DR
Second Line	:
City	:	CITRUS HEIGHTS
State	:	CA
Zip	:	95621-1937
Country	:	US
Telephone Number	:	916-725-6348
Fax Number	:

Provider Business Practice Location Address
First Line	:	6813 MARINVALE DR
Second Line	:
City	:	CITRUS HEIGHTS
State	:	CA
Zip	:	95621-1937
Country	:	US
Telephone Number	:	916-725-6348
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. NELSON SANTOS JACINTO
Credential	:
Telephone Number	:	916-725-6348

Provider Enumeration Date	:	10/15/2006
Last Update Date	:	07/08/2008

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Directions to “MACKELLAH HOME ” Practice Location

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