=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639096753
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SGBRC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2026
-----------------------------------------------------
Last Update Date | 06/30/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24596 DARDANIA AVE
-----------------------------------------------------
City | MISSION VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92691-4623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-637-0295
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24596 DARDANIA AVE
-----------------------------------------------------
City | MISSION VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92691-4623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-637-0295
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSEE
-----------------------------------------------------
Name | ALBERT DAHBOUR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-637-0295
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------