=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669334975
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVERETTE COMFORT RESIDENCY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2025
-----------------------------------------------------
Last Update Date | 11/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 63 DESERT WOOD CT
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95823-6215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-692-6347
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 63 DESERT WOOD CT
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95823-6215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-692-6347
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | RODNEYSHA E ELLINGTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-692-6347
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------