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General NPI Number Information
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NPI Number | 1417275967
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Entity Type | Organization
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Legal Business Name | D' VINE HOME
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Dates
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Enumeration Date | 05/07/2010
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Last Update Date | 05/07/2010
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Provider Practice Location Address
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Address Line | 16123 VINE ST
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City | HESPERIA
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State | CA
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Zip | 92345-3113
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Country | US
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Telephone | 760-981-4595
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Fax | 760-981-4501
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Provider Business Mailing Address
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Address Line | 18101 JUNIPER ST
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City | HESPERIA
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State | CA
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Zip | 92345-6324
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Country | US
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Telephone | 760-981-4595
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Fax | 760-981-4501
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. CONCEPCION GABRIEL PANOPIO
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Credential |
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Telephone | 760-371-5153
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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 | 366412235
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License Number State | CA
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