=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932643350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARKELL & MARQUELL ENTERPRISES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2016
-----------------------------------------------------
Last Update Date | 03/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15923 SAN MARCO PL
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93314-6650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-972-6235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 901
-----------------------------------------------------
City | TEHACHAPI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93581-0901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-972-6235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JASON JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 661-972-6235
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 157206784
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------