=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184013401
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTRY CLUB GUEST HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2015
-----------------------------------------------------
Last Update Date | 01/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25533 RUA MICHELLE
-----------------------------------------------------
City | ESCONDIDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92026-8600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-443-5795
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25533 RUA MICHELLE
-----------------------------------------------------
City | ESCONDIDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92026-8600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-443-5795
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MELANIE CUARESMA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 760-443-5795
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 372004630
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------