Provider Demographics
NPI:1154585883
Name:JERIDA LANE RESIDENTIAL CARE
Entity type:Organization
Organization Name:JERIDA LANE RESIDENTIAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ESTRELLITA
Authorized Official - Middle Name:DE MESA
Authorized Official - Last Name:OLEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-606-8241
Mailing Address - Street 1:8830 JERIDA LN
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-5470
Mailing Address - Country:US
Mailing Address - Phone:916-606-8241
Mailing Address - Fax:916-863-0668
Practice Address - Street 1:8830 JERIDA LN
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-5470
Practice Address - Country:US
Practice Address - Phone:916-606-8241
Practice Address - Fax:916-863-0668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA347003312320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities