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General NPI Number Information
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NPI Number | 1902051857
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Entity Type | Organization
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Legal Business Name | THE RESIDENCES-FAIR OAKS
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Dates
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Enumeration Date | 11/19/2008
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Last Update Date | 11/19/2008
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Provider Practice Location Address
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Address Line | 4804 CHICAGO AVE
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City | FAIR OAKS
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State | CA
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Zip | 95628-5224
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Country | US
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Telephone | 916-606-8241
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Fax | 916-863-0668
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Provider Business Mailing Address
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Address Line | 4804 CHICAGO AVE
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City | FAIR OAKS
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State | CA
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Zip | 95628-5224
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Country | US
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Telephone | 916-606-8241
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Fax | 916-863-0668
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Authorized Official
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Title or Position | LICENSEE/ADMINISTRATOR
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Name | MRS. ESTRELLITA DE MESA OLEA
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Credential | N/A
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Telephone | 916-606-8241
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320700000X
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Taxonomy Name | Physical Disabilities Residential Treatment Facility
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License Number | 347003929
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License Number State | CA
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