Provider Demographics
NPI:1083311757
Name:CITRUS CREST CARE HOME1
Entity Type:Organization
Organization Name:CITRUS CREST CARE HOME1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARIAM
Authorized Official - Middle Name:GBATY
Authorized Official - Last Name:SOUMAHORO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-409-7096
Mailing Address - Street 1:6906 HENNING DR
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95621-2840
Mailing Address - Country:US
Mailing Address - Phone:916-728-1338
Mailing Address - Fax:
Practice Address - Street 1:6906 HENNING DR
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95621-2840
Practice Address - Country:US
Practice Address - Phone:916-728-1338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility