=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609011618
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VETERANS HOME OF CALIFORNIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2008
-----------------------------------------------------
Last Update Date | 09/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 CALIFORNIA DR
-----------------------------------------------------
City | YOUNTVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94599-1411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-944-4622
-----------------------------------------------------
Fax | 707-948-3319
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 942895
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94295-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-653-0080
-----------------------------------------------------
Fax | 916-653-1795
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DONALD L. VEVERKA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 707-944-4501
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 15000494
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------