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Organization
TYSON HOME
Active
Organization
TYSON HOME
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. ELIZABETH KORDOVEZ CUIZON (MEDI-CAL BILLER)
(707) 812-0080
Entity
Organization
Contact information
Practice address
624 MINI DR, VALLEJO, CA 94589-1735
(707) 553-2798
Mailing address
PO BOX 1425, VALLEJO, CA 94590-0142
(707) 333-2005
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
—
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
LTC60826F
—
CA
Enumeration date
10/25/2006
Last updated
08/22/2020
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