Provider Demographics
NPI:1205002904
Name:ANTELOPE HILLS MANOR ICF DD-N INC.
Entity Type:Organization
Organization Name:ANTELOPE HILLS MANOR ICF DD-N INC.
Other - Org Name:KLAMATH HOME ICF DD-N
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:GAGANTE
Authorized Official - Last Name:RANIT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:916-721-9439
Mailing Address - Street 1:7704 ANTELOPE HILLS DR
Mailing Address - Street 2:
Mailing Address - City:ANTELOPE
Mailing Address - State:CA
Mailing Address - Zip Code:95843-2491
Mailing Address - Country:US
Mailing Address - Phone:916-721-1517
Mailing Address - Fax:916-721-0762
Practice Address - Street 1:5355 KLAMATH DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95842-2651
Practice Address - Country:US
Practice Address - Phone:916-332-1439
Practice Address - Fax:916-332-4716
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANTELOPE HILLS MANOR ICF DD-N INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000069320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC80373FOtherCALIFORNIA MEDI-CAL