MEDICARE: CAMELLIA ASSISTED LIVING

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	310400000X	Assisted Living Facility	347003786	CA

General Provider Information

NPI Number	:	1487085510
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMELLIA ASSISTED LIVING

Provider Business Mailing Address
First Line	:	4625 CHICAGO AVE
Second Line	:
City	:	FAIR OAKS
State	:	CA
Zip	:	95628-6034
Country	:	US
Telephone Number	:	916-962-7106
Fax Number	:	916-962-7106

Provider Business Practice Location Address
First Line	:	4625 CHICAGO AVE
Second Line	:
City	:	FAIR OAKS
State	:	CA
Zip	:	95628-6034
Country	:	US
Telephone Number	:	916-962-7106
Fax Number	:	916-962-7106

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. TISA CADWAY
Credential	:
Telephone Number	:	650-207-3667

Provider Enumeration Date	:	11/27/2013
Last Update Date	:	11/27/2013

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Directions to “CAMELLIA ASSISTED LIVING ” Practice Location

Language	Start Address	Practice Location

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