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General NPI Number Information
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NPI Number | 1336412113
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Entity Type | Organization
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Legal Business Name | PCM GROUP INC DBA MIRABEL LODGE
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Dates
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Enumeration Date | 02/09/2012
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Last Update Date | 02/09/2012
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Provider Practice Location Address
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Address Line | 6950 MIRABEL RD
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City | FORESTVILLE
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State | CA
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Zip | 95436-9534
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Country | US
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Telephone | 707-887-1754
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Fax | 707-887-0546
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Provider Business Mailing Address
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Address Line | PO BOX 1579
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City | FORESTVILLE
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State | CA
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Zip | 95436-1579
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Country | US
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Telephone | 707-887-1754
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Fax | 707-887-0546
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Authorized Official
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Title or Position | OWNER/ ADMINISTRATOR/ LICENCEE
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Name | MR. ALAIN A SERKISSIAN
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Credential |
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Telephone | 707-887-1754
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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 | 496800941
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 3104A0630X
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Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
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License Number | 496800941
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 311500000X
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Taxonomy Name | Alzheimer Center (Dementia Center)
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License Number | 496800941
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License Number State | CA
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