Basic Information
| Provider Information | |||||||||
| NPI: | 1699830448 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAVIS GUEST HOME, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1878 E HATCH RD | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953515002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095381496 | ||||||||
| FaxNumber: | 2095386584 | ||||||||
| Practice Location | |||||||||
| Address1: | 1878 E HATCH RD | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953515002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095381496 | ||||||||
| FaxNumber: | 2095386584 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | LONNY | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2094027900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | CA | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.