Healthcare Provider Details

I. General information

NPI: 1205636685
Provider Name (Legal Business Name): 716 ESTABLISHMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2025
Last Update Date: 03/15/2025
Certification Date: 03/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 DAPHNE DR
FAIRFIELD CA
94533-1114
US

IV. Provider business mailing address

1210 GULF DR
FAIRFIELD CA
94533-7099
US

V. Phone/Fax

Practice location:
  • Phone: 707-689-1774
  • Fax:
Mailing address:
  • Phone: 707-689-1774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. SALINA SMITH
Title or Position: COO
Credential: AMFT
Phone: 707-689-1774