Provider Demographics
NPI:1316164379
Name:CARPENTER GUEST HOMES INC
Entity type:Organization
Organization Name:CARPENTER GUEST HOMES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSEE/ADMIN
Authorized Official - Prefix:MRS
Authorized Official - First Name:ESTRELLA
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-462-4239
Mailing Address - Street 1:2482 CARPENTER RD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205
Mailing Address - Country:US
Mailing Address - Phone:209-932-0368
Mailing Address - Fax:209-932-0668
Practice Address - Street 1:3446 POCK LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-8022
Practice Address - Country:US
Practice Address - Phone:209-932-0368
Practice Address - Fax:209-932-0668
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARPENTER GUEST HOMES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-19
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100000685261QA0600X, 261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC60942GMedicare PIN
CA556319Medicare UPIN