Healthcare Provider Details

I. General information

NPI: 1346958485
Provider Name (Legal Business Name): LIVE OAK REST HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 LIVE OAK AVE
SEBASTOPOL CA
95472-3363
US

IV. Provider business mailing address

604 LIVE OAK AVE
SEBASTOPOL CA
95472-3363
US

V. Phone/Fax

Practice location:
  • Phone: 707-823-7277
  • Fax: 707-823-5462
Mailing address:
  • Phone: 707-514-6727
  • Fax: 707-823-5462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: MR. NICHOLAS LEON RAY
Title or Position: LICENSEE
Credential:
Phone: 707-514-6727