Provider Demographics
NPI:1841048808
Name:7117 MAIN
Entity type:Organization
Organization Name:7117 MAIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LISCENSEE
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-430-1608
Mailing Address - Street 1:7117 MAIN AVE # NA
Mailing Address - Street 2:
Mailing Address - City:ORANGEVALE
Mailing Address - State:CA
Mailing Address - Zip Code:95662-2813
Mailing Address - Country:US
Mailing Address - Phone:707-430-1608
Mailing Address - Fax:
Practice Address - Street 1:7117 MAIN AVE
Practice Address - Street 2:
Practice Address - City:ORANGEVALE
Practice Address - State:CA
Practice Address - Zip Code:95662-2813
Practice Address - Country:US
Practice Address - Phone:707-430-1608
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-07
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility