=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679448955
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHENIN BLANC ASSISTED LIVING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2025
-----------------------------------------------------
Last Update Date | 10/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5326 CHENIN BLANC PL
-----------------------------------------------------
City | VALLEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94591-8387
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-645-8168
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5326 CHENIN BLANC PL
-----------------------------------------------------
City | VALLEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94591-8387
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-645-8168
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | NIKIYAH JONES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-213-9128
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------