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General NPI Number Information
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NPI Number | 1649589623
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Entity Type | Organization
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Legal Business Name | SAGE HOUSE ADULT DAY CARE CENTER
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Dates
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Enumeration Date | 09/24/2010
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Last Update Date | 09/24/2010
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Provider Practice Location Address
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Address Line | 138 S BANDINI ST
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City | SAN PEDRO
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State | CA
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Zip | 90731-2321
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Country | US
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Telephone | 310-832-6031
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Fax | 310-832-6677
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Provider Business Mailing Address
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Address Line | 138 S BANDINI ST
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City | SAN PEDRO
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State | CA
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Zip | 90731-2321
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Country | US
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Telephone | 310-832-6031
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Fax | 310-832-6677
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Authorized Official
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Title or Position | EXEC. DIRECTOR
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Name | MR. GERALD LEWIS HARDIN
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Credential | BSM
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Telephone | 310-832-6031
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number | 198600603
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License Number State | CA
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