Healthcare Provider Details

I. General information

NPI: 1891380986
Provider Name (Legal Business Name): GREEN GABLES CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1549 DOUGLAS AVE
CLOVIS CA
93611-3124
US

IV. Provider business mailing address

PO BOX 2481
CANYON COUNTRY CA
91386-2481
US

V. Phone/Fax

Practice location:
  • Phone: 559-297-4152
  • Fax: 661-209-3076
Mailing address:
  • Phone: 559-307-0950
  • Fax: 661-209-3076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. LORIK SHEAKALEE
Title or Position: ADMINISTRATOR/OWNER
Credential:
Phone: 559-307-0950