Provider Demographics
NPI:1104976794
Name:GABRIEL ICF
Entity type:Organization
Organization Name:GABRIEL ICF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR RN
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:PAISTE
Authorized Official - Last Name:GABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:209-598-1436
Mailing Address - Street 1:2216 ALPINE DR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-6703
Mailing Address - Country:US
Mailing Address - Phone:209-333-0592
Mailing Address - Fax:209-368-2771
Practice Address - Street 1:2155 W ELM STREET
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-6703
Practice Address - Country:US
Practice Address - Phone:209-333-0592
Practice Address - Fax:209-368-2771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALTC80160F315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC80160FMedicaid