=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679912398
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MUM'S HOME SWEET HOME, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2013
-----------------------------------------------------
Last Update Date | 06/15/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6723 N SIERRA VISTA AVE
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93710-4840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-269-6828
-----------------------------------------------------
Fax | 559-298-8504
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6723 N SIERRA VISTA AVE
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93710-4840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-269-6828
-----------------------------------------------------
Fax | 559-298-8504
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | DARYL MUMFORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 559-269-6828
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number | 107201724
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------