Healthcare Provider Details

I. General information

NPI: 1881511939
Provider Name (Legal Business Name): MINA'S SENIOR LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10163 DORMER WAY
ELK GROVE CA
95757-1744
US

IV. Provider business mailing address

10163 DORMER WAY
ELK GROVE CA
95757-1744
US

V. Phone/Fax

Practice location:
  • Phone: 916-776-7060
  • Fax:
Mailing address:
  • Phone: 916-776-7060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MARIATOU SISAY
Title or Position: LICENSEE
Credential:
Phone: 916-776-7060