Healthcare Provider Details

I. General information

NPI: 1558790618
Provider Name (Legal Business Name): KECHI SUPPORTED LIVING, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2013
Last Update Date: 11/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51079 LONE TREE WAY
ANTIOCH CA
94531-8689
US

IV. Provider business mailing address

1148 LAKE PARK DR
OAKLEY CA
94561-3510
US

V. Phone/Fax

Practice location:
  • Phone: 925-476-8872
  • Fax: 925-679-7067
Mailing address:
  • Phone: 510-472-6259
  • Fax: 925-679-7067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: SARIETTE METAGHEU
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 925-476-8872