Healthcare Provider Details

I. General information

NPI: 1366951246
Provider Name (Legal Business Name): MAGENTA HAZE PUBLIC RELATIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2017
Last Update Date: 09/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 E VERNALIS RD
TRACY CA
95304-9376
US

IV. Provider business mailing address

1500 GOLDENBAY AVE APT 111
SAN RAMON CA
94582-5863
US

V. Phone/Fax

Practice location:
  • Phone: 510-372-5830
  • Fax:
Mailing address:
  • Phone: 925-217-4833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code315D00000X
TaxonomyInpatient Hospice
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State

VIII. Authorized Official

Name: SHELYNG KNICOLE MCCOVERY
Title or Position: ADMINISTRATOR
Credential: LVN
Phone: 925-217-4833