Organization
MY HOME INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. HORTENSIA MARIE SANDOVAL (BOOKKEEPER)
(707) 527-5744
Entity
Organization
Contact information
Practice address
1639 MANZANITA AVENUE, SANTA ROSA, CA 95404
(707) 539-7435
(707) 539-7435
Mailing address
1983 MT OLIVE DR, SANTA ROSA, CA 95404
(707) 527-5744
(707) 527-5744
Taxonomy
Speciality
Code
Description
License number
State
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
LTC60758F
—
CA
Enumeration date
01/31/2007
Last updated
08/22/2020
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