=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982429247
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGATE CONGREGATE LIVING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2024
-----------------------------------------------------
Last Update Date | 11/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13968 AGATE CT
-----------------------------------------------------
City | EASTVALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92880-3834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-233-1645
-----------------------------------------------------
Fax | 951-220-7169
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6835 RIVERGLEN CT
-----------------------------------------------------
City | EASTVALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92880-3842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-233-1645
-----------------------------------------------------
Fax | 951-220-7169
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | MR. SIMM K SANASINH
-----------------------------------------------------
Credential | OWNER
-----------------------------------------------------
Telephone | 949-233-1645
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------