Provider Demographics
NPI:1225236953
Name:MILES RAE LANE HOUSE
Entity Type:Organization
Organization Name:MILES RAE LANE HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:LLOYD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-897-3138
Mailing Address - Street 1:1649 CENTER RD
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-3941
Mailing Address - Country:US
Mailing Address - Phone:415-897-3138
Mailing Address - Fax:
Practice Address - Street 1:858 RAE LN
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-2049
Practice Address - Country:US
Practice Address - Phone:415-897-3138
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05G790320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities