=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083401665
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEQUOIA HEALTH & CARE RESIDENCE CONGREGATE CARE HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2025
-----------------------------------------------------
Last Update Date | 04/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13361 SEQUOIA RD
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92392-9796
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-686-9676
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13361 SEQUOIA RD
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92392-9796
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-686-9676
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MISS JEANNETTE PHILLIPS
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 310-686-9676
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311Z00000X
-----------------------------------------------------
Taxonomy Name | Custodial Care Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------