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General NPI Number Information
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NPI Number | 1104357102
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Entity Type | Organization
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Legal Business Name | KOOBAMO,LLC
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Dates
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Enumeration Date | 03/22/2017
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Last Update Date | 03/22/2017
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Provider Practice Location Address
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Address Line | 5472 FOOTHILL BLVD
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City | OAKLAND
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State | CA
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Zip | 94601-5516
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Country | US
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Telephone | 408-202-2236
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Fax |
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Provider Business Mailing Address
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Address Line | 5472 FOOTHILL BLVD
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City | OAKLAND
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State | CA
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Zip | 94601-5516
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Country | US
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Telephone | 408-202-2236
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | HASMIN KOO
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Credential |
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Telephone | 408-202-2236
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 019200695
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License Number State | CA
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