Provider Demographics
NPI:1477011740
Name:KOINONIA FOSTER HOMES, INC.
Entity Type:Organization
Organization Name:KOINONIA FOSTER HOMES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:RYLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-652-0171
Mailing Address - Street 1:PO BOX 1403
Mailing Address - Street 2:
Mailing Address - City:LOOMIS
Mailing Address - State:CA
Mailing Address - Zip Code:95650-1403
Mailing Address - Country:US
Mailing Address - Phone:916-652-0171
Mailing Address - Fax:
Practice Address - Street 1:3880 OAK TREE LN
Practice Address - Street 2:
Practice Address - City:LOOMIS
Practice Address - State:CA
Practice Address - Zip Code:95650-9316
Practice Address - Country:US
Practice Address - Phone:916-652-0171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA317000017Medicaid