Basic Information
Provider Information | |||||||||
NPI: | 1588080451 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GRACEVILLA,INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 540 W MONTE VISTA AVE | ||||||||
Address2: |   | ||||||||
City: | VACAVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 956883620 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074493400 | ||||||||
FaxNumber: | 7074500954 | ||||||||
Practice Location | |||||||||
Address1: | 723 E 9TH ST | ||||||||
Address2: |   | ||||||||
City: | LONG BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 908134611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5624912797 | ||||||||
FaxNumber: | 5624910945 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2014 | ||||||||
LastUpdateDate: | 03/14/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SINGH | ||||||||
AuthorizedOfficialFirstName: | TRILOCHAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 5104681909 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 940000032 | CA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.