MEDICARE: SCOTTSDALE 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	347000357	CA

General Provider Information

NPI Number	:	1679635601
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCOTTSDALE GUEST HOME

Provider Business Mailing Address
First Line	:	8047 ROCKHURST WAY
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95828
Country	:	US
Telephone Number	:
Fax Number	:	916-688-7745

Provider Business Practice Location Address
First Line	:	8047 ROCKHURST WAY
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95828-4226
Country	:	US
Telephone Number	:	916-682-2305
Fax Number	:	916-688-7745

Authorized Official
Title or Position	:	OWNER ADMINISTRATOR
Name	:	CORAZON DE ALA EPISCOPE
Credential	:
Telephone Number	:	916-682-2305

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	06/23/2008

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