=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992057244
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOLIDUM CARE HOME ICFDD-N#2
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2012
-----------------------------------------------------
Last Update Date | 10/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9559 COLINGTON PL
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95209-5013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-474-6785
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2114 CODY CT
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95209-1212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORPORATE OFFICER
-----------------------------------------------------
Name | NORMA SOLIDUM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 209-474-6785
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 550001684
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------