Healthcare Provider Details

I. General information

NPI: 1982769907
Provider Name (Legal Business Name): CERBAT GUEST HOME INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2364 E CARVER AVE
KINGMAN AZ
86409-1224
US

IV. Provider business mailing address

2364 E CARVER AVE
KINGMAN AZ
86409-1224
US

V. Phone/Fax

Practice location:
  • Phone: 928-757-3989
  • Fax:
Mailing address:
  • Phone: 928-757-3989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberALC-2600
License Number StateAZ

VIII. Authorized Official

Name: MRS. SANDRA DARLENE SCHMITZ
Title or Position: SECRETARY,OWNER,MANAGER
Credential:
Phone: 928-753-3731