=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255938015
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEWPORT LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2020
-----------------------------------------------------
Last Update Date | 02/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2030 EVERGREEN AVE
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95350-3785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-899-1315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 599 MENLO DR STE 200
-----------------------------------------------------
City | ROCKLIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95765-3725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-899-1315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | RYAN WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-945-1248
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------