Provider Demographics
NPI:1881876779
Name:ST DOMINICS SENIOR CARE HOME
Entity type:Organization
Organization Name:ST DOMINICS SENIOR CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EMELITA
Authorized Official - Middle Name:JOSON
Authorized Official - Last Name:CINCO
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:671-632-9370
Mailing Address - Street 1:350 NORTH SABANA DRIVE
Mailing Address - Street 2:
Mailing Address - City:BARRIGADA HEIGHTS
Mailing Address - State:GU
Mailing Address - Zip Code:96913-1262
Mailing Address - Country:US
Mailing Address - Phone:671-632-9370
Mailing Address - Fax:671-637-1679
Practice Address - Street 1:350 NORTH SABANA DRIVE
Practice Address - Street 2:
Practice Address - City:BARRIGADA HEIGHTS
Practice Address - State:GU
Practice Address - Zip Code:96913-1262
Practice Address - Country:US
Practice Address - Phone:671-632-9370
Practice Address - Fax:671-637-1679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GU2007001313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GU405OtherMEDICALLY INDIGENT PROGRA