=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245443910
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENEVIE DREAM HOME, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17355 BUENA VISTA AVE
-----------------------------------------------------
City | SONOMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95476-3493
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-935-9411
-----------------------------------------------------
Fax | 707-935-9411
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17355 BUENA VISTA AVE
-----------------------------------------------------
City | SONOMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95476-3493
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-935-9411
-----------------------------------------------------
Fax | 707-935-9411
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. REY B. RAMIREZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 650-580-0753
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------