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General NPI Number Information
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NPI Number | 1699850016
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Entity Type | Organization
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Legal Business Name | TYSON HOME
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Dates
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Enumeration Date | 10/25/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 624 MINI DR
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City | VALLEJO
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State | CA
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Zip | 94589-1735
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Country | US
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Telephone | 707-553-2798
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1425
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City | VALLEJO
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State | CA
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Zip | 94590-0142
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Country | US
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Telephone | 707-333-2005
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Fax |
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Authorized Official
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Title or Position | MEDI-CAL BILLER
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Name | MS. ELIZABETH KORDOVEZ CUIZON
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Credential |
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Telephone | 707-812-0080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number |
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License Number State | CA
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