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General NPI Number Information
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NPI Number | 1922463439
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Entity Type | Organization
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Legal Business Name | BALTIC SEA MANOR
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Dates
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Enumeration Date | 12/28/2015
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Last Update Date | 12/28/2015
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Provider Practice Location Address
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Address Line | 5227 OAKRIDGE DR
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City | FAIRFIELD
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State | CA
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Zip | 94534-6619
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Country | US
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Telephone | 925-783-0988
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Fax | 707-864-1777
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Provider Business Mailing Address
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Address Line | 5227 OAKRIDGE DR
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City | FAIRFIELD
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State | CA
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Zip | 94534-6619
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Country | US
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Telephone | 925-783-0988
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Fax | 707-864-1777
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. VIVIAN ROSE PRICE
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Credential | LICENSED RCFE
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Telephone | 925-783-0988
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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 | 075601459
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 320700000X
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Taxonomy Name | Physical Disabilities Residential Treatment Facility
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License Number | 075601569
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License Number State | CA
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