Provider Demographics
NPI:1508435801
Name:MILLBRAE ASSISTED LIVING HOME LLC
Entity Type:Organization
Organization Name:MILLBRAE ASSISTED LIVING HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:
Authorized Official - Last Name:PO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-648-2737
Mailing Address - Street 1:23 CORPORATE PLAZA DR STE 150
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7908
Mailing Address - Country:US
Mailing Address - Phone:949-833-7108
Mailing Address - Fax:
Practice Address - Street 1:1001 HEMLOCK AVE
Practice Address - Street 2:
Practice Address - City:MILLBRAE
Practice Address - State:CA
Practice Address - Zip Code:94030-2046
Practice Address - Country:US
Practice Address - Phone:650-689-5776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-21
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility