Healthcare Provider Details

I. General information

NPI: 1164041687
Provider Name (Legal Business Name): HALLEY IRENE CRUMB ADULT RESIDENTIAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16236 N LAKE ST
MADERA CA
93638-1615
US

IV. Provider business mailing address

2785 JOSEPH AVE APT 4
CAMPBELL CA
95008-6259
US

V. Phone/Fax

Practice location:
  • Phone: 650-461-0433
  • Fax:
Mailing address:
  • Phone: 650-461-0433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number6031500735
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: