MEDICARE: CITRUS CREST CARE HOME 2 LLC

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1841910247
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITRUS CREST CARE HOME 2 LLC

Provider Business Mailing Address
First Line	:	6813 MARINVALE DR
Second Line	:
City	:	CITRUS HEIGHTS
State	:	CA
Zip	:	95621-1937
Country	:	US
Telephone Number	:	510-409-7098
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	:	510-409-7098
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MUAMOUDOU AIDARA SOUMAHORO
Credential	:
Telephone Number	:	510-509-7098

Provider Enumeration Date	:	08/29/2022
Last Update Date	:	08/29/2022

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