Healthcare Provider Details

I. General information

NPI: 1376607929
Provider Name (Legal Business Name): KIMBERLY & BEVERLY'S GUEST HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10100 COUNTRYSIDE WAY
SACRAMENTO CA
95827-5517
US

IV. Provider business mailing address

2218 BUCKS CREEK CT
GOLD RIVER CA
95670-8121
US

V. Phone/Fax

Practice location:
  • Phone: 916-366-3111
  • Fax: 916-638-8880
Mailing address:
  • Phone: 916-631-7969
  • Fax: 916-638-8880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number340312905
License Number StateCA

VIII. Authorized Official

Name: MR. MIKE G TAMPUS
Title or Position: OWNER
Credential:
Phone: 916-631-7969