Provider Demographics
NPI:1366168296
Name:MIRABEL LODGE
Entity type:Organization
Organization Name:MIRABEL LODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:VARSHAVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-264-5486
Mailing Address - Street 1:6950 MIRABEL RD
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95436-9534
Mailing Address - Country:US
Mailing Address - Phone:415-264-5486
Mailing Address - Fax:
Practice Address - Street 1:6950 MIRABEL RD
Practice Address - Street 2:
Practice Address - City:FORESTVILLE
Practice Address - State:CA
Practice Address - Zip Code:95436-9534
Practice Address - Country:US
Practice Address - Phone:415-264-5486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility