Provider Demographics
NPI:1316315146
Name:CHENEY HOME ICF-DD/N II
Entity type:Organization
Organization Name:CHENEY HOME ICF-DD/N II
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RN/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:I
Authorized Official - Last Name:REGINALDO-ROXAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-861-2635
Mailing Address - Street 1:1755 CANTERBURY LN
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-8710
Mailing Address - Country:US
Mailing Address - Phone:510-861-2635
Mailing Address - Fax:510-293-0365
Practice Address - Street 1:2166 BOCA RATON ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-3534
Practice Address - Country:US
Practice Address - Phone:510-293-0360
Practice Address - Fax:510-293-0365
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHENEY HOME ICF-DD/N
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550002962313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility