Basic Information
Provider Information | |||||||||
NPI: | 1629570932 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KOINONIA FOSTER HOMES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KOINONIA FAMILY SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1403 | ||||||||
Address2: |   | ||||||||
City: | LOOMIS | ||||||||
State: | CA | ||||||||
PostalCode: | 956501403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9166525802 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5465 AGUILAR RD | ||||||||
Address2: |   | ||||||||
City: | ROCKLIN | ||||||||
State: | CA | ||||||||
PostalCode: | 956773302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9166525814 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2018 | ||||||||
LastUpdateDate: | 10/05/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MILLER | ||||||||
AuthorizedOfficialFirstName: | JESSICA | ||||||||
AuthorizedOfficialMiddleName: | MARGUERITE | ||||||||
AuthorizedOfficialTitleorPosition: | MENTAL HEALTH HEAD OF SERVICE | ||||||||
AuthorizedOfficialTelephone: | 9166525814 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LCSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | N |   | Agencies | Community/Behavioral Health |   | 253J00000X | 317000912 | CA | Y |   | Agencies | Foster Care Agency |   |
No ID Information.