Provider Demographics
NPI:1619574225
Name:GAVANA CORPORATION
Entity Type:Organization
Organization Name:GAVANA CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:LACKHENA
Authorized Official - Middle Name:
Authorized Official - Last Name:MURALLON
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:916-302-4243
Mailing Address - Street 1:4065 SOUTHAMPTON ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-4241
Mailing Address - Country:US
Mailing Address - Phone:209-817-4739
Mailing Address - Fax:
Practice Address - Street 1:5842 LONETREE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-3785
Practice Address - Country:US
Practice Address - Phone:916-302-4243
Practice Address - Fax:916-302-4730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA253Z00000XMedicaid