MEDICARE: MS. HALLEY IRENE CRUMB ADULT RESIDENTIAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747A0650X	Attendant Care Provider	6031500735	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6031500735	OTHER	CA	COMMUNITY CARE LICENSE DIVISION

General Provider Information

NPI Number	:	1164041687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. HALLEY IRENE CRUMB ADULT RESIDENTIAL

Provider Business Mailing Address
First Line	:	2785 JOSEPH AVE APT 4
Second Line	:
City	:	CAMPBELL
State	:	CA
Zip	:	95008-6259
Country	:	US
Telephone Number	:	650-461-0433
Fax Number	:

Provider Business Practice Location Address
First Line	:	16236 N LAKE ST
Second Line	:
City	:	MADERA
State	:	CA
Zip	:	93638-1615
Country	:	US
Telephone Number	:	650-461-0433
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2020
Last Update Date	:	06/16/2021

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