Provider Demographics
NPI:1699850016
Name:TYSON HOME
Entity Type:Organization
Organization Name:TYSON HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDI-CAL BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:KORDOVEZ
Authorized Official - Last Name:CUIZON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-812-0080
Mailing Address - Street 1:PO BOX 1425
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-0142
Mailing Address - Country:US
Mailing Address - Phone:707-333-2005
Mailing Address - Fax:
Practice Address - Street 1:624 MINI DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-1735
Practice Address - Country:US
Practice Address - Phone:707-553-2798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC60826FMedicaid