Provider Demographics
NPI:1528386786
Name:ANTELOPE HILLS MANOR ICF/DD-N INC.
Entity Type:Organization
Organization Name:ANTELOPE HILLS MANOR ICF/DD-N INC.
Other - Org Name:TULLIA PLACE ICF/DD-N
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:G
Authorized Official - Last Name:RANIT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:916-548-1397
Mailing Address - Street 1:9500 LITTORAL ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-9168
Mailing Address - Country:US
Mailing Address - Phone:916-548-1397
Mailing Address - Fax:916-721-9439
Practice Address - Street 1:8533 TULLIA PL
Practice Address - Street 2:
Practice Address - City:ANTELOPE
Practice Address - State:CA
Practice Address - Zip Code:95843-5986
Practice Address - Country:US
Practice Address - Phone:916-548-1397
Practice Address - Fax:916-721-9439
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANTELOPE HILLS MANOR ICF/DD-N INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities