Provider Demographics
NPI:1770622292
Name:ANTELOPE HILLS MANOR ICF DDN INC
Entity type:Organization
Organization Name:ANTELOPE HILLS MANOR ICF DDN INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RN ADMINISTRATOR QMRP
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:GAGANTE
Authorized Official - Last Name:RANIT
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:916-721-9439
Mailing Address - Street 1:7704 ANTELOPE HILLS DR
Mailing Address - Street 2:
Mailing Address - City:ANTELOPE
Mailing Address - State:CA
Mailing Address - Zip Code:95843-2491
Mailing Address - Country:US
Mailing Address - Phone:916-721-1517
Mailing Address - Fax:916-721-0762
Practice Address - Street 1:7704 ANTELOPE HILLS DR
Practice Address - Street 2:
Practice Address - City:ANTELOPE
Practice Address - State:CA
Practice Address - Zip Code:95843-2491
Practice Address - Country:US
Practice Address - Phone:916-721-1517
Practice Address - Fax:916-721-0762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC80373FMedicaid
CALTC80334FMedicaid