=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245178516
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUNDATION LIVING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2026
-----------------------------------------------------
Last Update Date | 03/24/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9800 BRUCEVILLE RD
-----------------------------------------------------
City | ELK GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95757-9536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-373-2056
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 531 EUREKA AVE
-----------------------------------------------------
City | LODI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95240-1015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOBER LIVING HOME OWNER
-----------------------------------------------------
Name | MOSES RODRIGUEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 408-373-2056
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------