=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508942111
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRIENDS ASSOC OF SERVICES FOR THE ELDERLY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2006
-----------------------------------------------------
Last Update Date | 07/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 684 BENICIA DRIVE
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95409-3058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-538-0152
-----------------------------------------------------
Fax | 707-573-4528
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 684 BENICIA DRIVE
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95409-3058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-538-0152
-----------------------------------------------------
Fax | 707-573-4528
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR. DIRECTOR RISK MANAGEMENT
-----------------------------------------------------
Name | GRANT EDELSTONE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 925-956-7360
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------