Healthcare Provider Details

I. General information

NPI: 1073404208
Provider Name (Legal Business Name): ETHEL GUMBAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2025
Last Update Date: 07/15/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 OAKMONT DR
SAN BRUNO CA
94066-1241
US

IV. Provider business mailing address

2700 OAKMONT DR
SAN BRUNO CA
94066-1241
US

V. Phone/Fax

Practice location:
  • Phone: 650-583-3496
  • Fax:
Mailing address:
  • Phone: 650-583-3496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number415600425
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: