=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194253609
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SENTINEL GARDENS CORP. INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2017
-----------------------------------------------------
Last Update Date | 11/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 MONEY ST
-----------------------------------------------------
City | GLADEWATER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75647-2523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 430-702-4000
-----------------------------------------------------
Fax | 323-389-1799
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 480762
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-9362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 430-702-4000
-----------------------------------------------------
Fax | 323-389-1799
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | JAMES SALAMON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 430-702-4000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number | 106456
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 106456
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------