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General NPI Number Information
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NPI Number | 1245617620
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Entity Type | Organization
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Legal Business Name | MAGNOLIA GUEST HOME LLC
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Dates
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Enumeration Date | 05/05/2015
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Last Update Date | 09/13/2019
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Provider Practice Location Address
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Address Line | 1639 FAIRWOOD DR
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City | CONCORD
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State | CA
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Zip | 94521
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Country | US
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Telephone | 925-642-0427
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Fax |
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Provider Business Mailing Address
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Address Line | 292 ROYCE WAY
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City | PITTSBURG
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State | CA
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Zip | 94565-4700
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Country | US
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Telephone | 925-427-9070
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. GENE LOBATON GEPULLE JR.
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Credential |
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Telephone | 925-642-0427
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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 | 079200401
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License Number State | CA
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