Provider Demographics
NPI:1417275967
Name:D' VINE HOME
Entity Type:Organization
Organization Name:D' VINE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONCEPCION
Authorized Official - Middle Name:GABRIEL
Authorized Official - Last Name:PANOPIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-371-5153
Mailing Address - Street 1:18101 JUNIPER ST
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-6324
Mailing Address - Country:US
Mailing Address - Phone:760-981-4595
Mailing Address - Fax:760-981-4501
Practice Address - Street 1:16123 VINE ST
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-3113
Practice Address - Country:US
Practice Address - Phone:760-981-4595
Practice Address - Fax:760-981-4501
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GLECO LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-07
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA366412235310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility