Provider Demographics
NPI:1881146843
Name:BOUGAINVILLEAS CARE LLC
Entity type:Organization
Organization Name:BOUGAINVILLEAS CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LIWAYWAY
Authorized Official - Middle Name:
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-580-5008
Mailing Address - Street 1:201 ALTA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-5702
Mailing Address - Country:US
Mailing Address - Phone:650-737-0832
Mailing Address - Fax:650-737-0834
Practice Address - Street 1:201 ALTA VISTA DR
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-5702
Practice Address - Country:US
Practice Address - Phone:650-737-0832
Practice Address - Fax:650-737-0834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA415600721310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility