Provider Demographics
NPI:1164663746
Name:PACIFIC HOME CA
Entity Type:Organization
Organization Name:PACIFIC HOME CA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSEE
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSALINE
Authorized Official - Middle Name:B
Authorized Official - Last Name:TANGLAO
Authorized Official - Suffix:
Authorized Official - Credentials:RC
Authorized Official - Phone:310-518-5178
Mailing Address - Street 1:254 E 220TH ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-3012
Mailing Address - Country:US
Mailing Address - Phone:310-518-5178
Mailing Address - Fax:310-518-5005
Practice Address - Street 1:254 E 220TH ST
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-3012
Practice Address - Country:US
Practice Address - Phone:310-518-5178
Practice Address - Fax:310-518-5005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities