=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083795595
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HUMANGOOD NORCAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 06/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 373 PINE LN
-----------------------------------------------------
City | LOS ALTOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-948-8291
-----------------------------------------------------
Fax | 650-941-0372
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 HUNTINGTON DR
-----------------------------------------------------
City | DUARTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91010-2694
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-247-0420
-----------------------------------------------------
Fax | 949-528-2434
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF ACCOUNTS RECEIVABLE
-----------------------------------------------------
Name | GWEN VANGELISTO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-463-0893
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 430708050
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------