Provider Demographics
NPI:1336412113
Name:PCM GROUP INC DBA MIRABEL LODGE
Entity Type:Organization
Organization Name:PCM GROUP INC DBA MIRABEL LODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ ADMINISTRATOR/ LICENCEE
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SERKISSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-887-1754
Mailing Address - Street 1:PO BOX 1579
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95436-1579
Mailing Address - Country:US
Mailing Address - Phone:707-887-1754
Mailing Address - Fax:707-887-0546
Practice Address - Street 1:6950 MIRABEL RD
Practice Address - Street 2:
Practice Address - City:FORESTVILLE
Practice Address - State:CA
Practice Address - Zip Code:95436-9534
Practice Address - Country:US
Practice Address - Phone:707-887-1754
Practice Address - Fax:707-887-0546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA496800941310400000X, 3104A0630X, 311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances