Basic Information
| Provider Information | |||||||||
| NPI: | 1922757012 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILLARD PEAK GROUP HOME, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29222 RANCHO VIEJO RD STE 127 | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN CAPISTRANO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926751049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495401249 | ||||||||
| FaxNumber: | 9495401966 | ||||||||
| Practice Location | |||||||||
| Address1: | 29222 RANCHO VIEJO RD STE 127 | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN CAPISTRANO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926751049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495401249 | ||||||||
| FaxNumber: | 9495401966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2022 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | BURNAM | ||||||||
| AuthorizedOfficialFirstName: | SOON | ||||||||
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| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 9495401249 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
No ID Information.