Provider Demographics
NPI:1770620734
Name:MY HOME INC
Entity type:Organization
Organization Name:MY HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:MS
Authorized Official - First Name:HORTENSIA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-527-5744
Mailing Address - Street 1:1983 MT OLIVE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404
Mailing Address - Country:US
Mailing Address - Phone:707-527-5744
Mailing Address - Fax:707-527-5744
Practice Address - Street 1:1639 MANZANITA AVENUE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404
Practice Address - Country:US
Practice Address - Phone:707-539-7435
Practice Address - Fax:707-539-7435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC60758FMedicaid
=========OtherTAX ID