MEDICARE: CHENEY HOME ICF-DD/N II

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	313M00000X	Nursing Facility/Intermediate Care Facility	550002962	CA

General Provider Information

NPI Number	:	1316315146
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHENEY HOME ICF-DD/N II

Provider Business Mailing Address
First Line	:	1755 CANTERBURY LN
Second Line	:
City	:	HAYWARD
State	:	CA
Zip	:	94544-8710
Country	:	US
Telephone Number	:	510-861-2635
Fax Number	:	510-293-0365

Provider Business Practice Location Address
First Line	:	2166 BOCA RATON ST
Second Line	:
City	:	HAYWARD
State	:	CA
Zip	:	94545-3534
Country	:	US
Telephone Number	:	510-293-0360
Fax Number	:	510-293-0365

Authorized Official
Title or Position	:	RN/ADMINISTRATOR
Name	:	RITA I REGINALDO-ROXAS
Credential	:
Telephone Number	:	510-861-2635

Provider Enumeration Date	:	09/10/2015
Last Update Date	:	09/10/2015

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