=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962900852
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. CHRIS FAAMAUSILI
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2018
-----------------------------------------------------
Last Update Date | 12/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5205 ARGO WAY
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95820-5737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-823-5117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16930 OAK TREE AVE
-----------------------------------------------------
City | COTTONWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96022-9683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-670-2647
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376G00000X
-----------------------------------------------------
Taxonomy Name | Nursing Home Administrator
-----------------------------------------------------
License Number | 342700024
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------