Provider Demographics
NPI:1164120390
Name:VALLONE TRISTAN CIRCLE LLC
Entity Type:Organization
Organization Name:VALLONE TRISTAN CIRCLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GODWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:AKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-225-0349
Mailing Address - Street 1:PO BOX 2944
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95344-0944
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:96 TRISTAN CIR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-4145
Practice Address - Country:US
Practice Address - Phone:916-392-1968
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities