Provider Demographics
NPI:1013131671
Name:B & M INC. - FLEETWOOD
Entity type:Organization
Organization Name:B & M INC. - FLEETWOOD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEGARDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-273-8181
Mailing Address - Street 1:52 POINTE VIEW PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-1673
Mailing Address - Country:US
Mailing Address - Phone:650-273-8181
Mailing Address - Fax:650-359-7865
Practice Address - Street 1:2796 FLEETWOOD DR
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-2627
Practice Address - Country:US
Practice Address - Phone:650-273-8181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
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
CALTC60947FMedicaid