Healthcare Provider Details

I. General information

NPI: 1629848056
Provider Name (Legal Business Name): GRACEFUL LIVING MVN CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 MOUNT VERNON CIR
VACAVILLE CA
95688-9495
US

IV. Provider business mailing address

548 MARKET ST
SAN FRANCISCO CA
94104-5401
US

V. Phone/Fax

Practice location:
  • Phone: 707-492-5849
  • Fax:
Mailing address:
  • Phone: 510-590-7095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: JANAE R MALBROUGH
Title or Position: CEO
Credential:
Phone: 510-590-7095