=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326580127
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | C & J HOMES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2016
-----------------------------------------------------
Last Update Date | 11/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1314 VINE ST
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98354-9261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-289-8059
-----------------------------------------------------
Fax | 253-952-6081
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1314 VINE ST
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98354-9261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-289-8059
-----------------------------------------------------
Fax | 253-952-6081
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. SHEENA CASSANDRA KENNEDY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 650-289-8059
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 752903
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------