MEDICARE: GREEN PASTURE GUEST HOME

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	311ZA0620X	Adult Care Home Facility	340308522	CA

General Provider Information

NPI Number	:	1598848269
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN PASTURE GUEST HOME

Provider Business Mailing Address
First Line	:	4604 ROOSEVELT AVE
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95820-4520
Country	:	US
Telephone Number	:	916-457-3129
Fax Number	:

Provider Business Practice Location Address
First Line	:	4604 ROOSEVELT AVE
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95820-4520
Country	:	US
Telephone Number	:	916-457-3129
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	GARY TATEISHI
Credential	:
Telephone Number	:	916-457-3129

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	06/25/2008

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Directions to “GREEN PASTURE GUEST HOME ” Practice Location

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