Provider Demographics
NPI:1225469307
Name:CALIFORNIA DEPARTMENT OF VETERANS AFFAIRS - FRESNO HOME
Entity Type:Organization
Organization Name:CALIFORNIA DEPARTMENT OF VETERANS AFFAIRS - FRESNO HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROJIRIO
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA CERDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-493-4241
Mailing Address - Street 1:2811 W CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93706-2307
Mailing Address - Country:US
Mailing Address - Phone:559-493-4400
Mailing Address - Fax:559-493-4204
Practice Address - Street 1:2811 W CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-2307
Practice Address - Country:US
Practice Address - Phone:559-493-4400
Practice Address - Fax:559-493-4204
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CALIFORNIA DEPARTMENT OF VETERANS AFFAIRS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-27
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107206701310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility