Provider Demographics
NPI:1750388732
Name:FELLOWSHIP HOME, INC
Entity type:Organization
Organization Name:FELLOWSHIP HOME, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-529-4950
Mailing Address - Street 1:1745 ELDENA WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-3568
Mailing Address - Country:US
Mailing Address - Phone:209-529-4950
Mailing Address - Fax:209-529-0957
Practice Address - Street 1:1745 ELDENA WAY
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-3568
Practice Address - Country:US
Practice Address - Phone:209-529-4950
Practice Address - Fax:209-529-0957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-05
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA500300107310400000X
CA507000572310400000X
CA507000573310400000X
CA507000802310400000X
CA100000019314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05A047Medicaid
CA05A047Medicaid