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General NPI Number Information
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NPI Number | 1619574225
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Entity Type | Organization
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Legal Business Name | GAVANA CORPORATION
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Dates
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Enumeration Date | 10/06/2020
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Last Update Date | 10/06/2020
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Provider Practice Location Address
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Address Line | 5842 LONETREE BLVD
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City | ROCKLIN
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State | CA
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Zip | 95765-3785
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Country | US
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Telephone | 916-302-4243
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Fax | 916-302-4730
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Provider Business Mailing Address
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Address Line | 4065 SOUTHAMPTON ST
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City | ROSEVILLE
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State | CA
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Zip | 95747-4241
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Country | US
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Telephone | 209-817-4739
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MISS LACKHENA MURALLON
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Credential | RN, BSN
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Telephone | 916-302-4243
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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