Healthcare Provider Details

I. General information

NPI: 1336412113
Provider Name (Legal Business Name): PCM GROUP INC DBA MIRABEL LODGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2012
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6950 MIRABEL RD
FORESTVILLE CA
95436-9534
US

IV. Provider business mailing address

PO BOX 1579
FORESTVILLE CA
95436-1579
US

V. Phone/Fax

Practice location:
  • Phone: 707-887-1754
  • Fax: 707-887-0546
Mailing address:
  • Phone: 707-887-1754
  • Fax: 707-887-0546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number496800941
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number496800941
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number496800941
License Number StateCA

VIII. Authorized Official

Name: MR. ALAIN A SERKISSIAN
Title or Position: OWNER/ ADMINISTRATOR/ LICENCEE
Credential:
Phone: 707-887-1754