Provider Demographics
NPI:1538048962
Name:PORCINI LLC WILD ROSE LIVING
Entity type:Organization
Organization Name:PORCINI LLC WILD ROSE LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-291-5756
Mailing Address - Street 1:1172 WILD ROSE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-5058
Mailing Address - Country:US
Mailing Address - Phone:707-291-5756
Mailing Address - Fax:707-838-0820
Practice Address - Street 1:1172 WILD ROSE DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5058
Practice Address - Country:US
Practice Address - Phone:707-291-5756
Practice Address - Fax:707-838-0820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-29
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility