Provider Demographics
NPI:1841910247
Name:CITRUS CREST CARE HOME 2 LLC
Entity type:Organization
Organization Name:CITRUS CREST CARE HOME 2 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MUAMOUDOU
Authorized Official - Middle Name:AIDARA
Authorized Official - Last Name:SOUMAHORO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-509-7098
Mailing Address - Street 1:6813 MARINVALE DR
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95621-1937
Mailing Address - Country:US
Mailing Address - Phone:510-409-7098
Mailing Address - Fax:
Practice Address - Street 1:6813 MARINVALE DR
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95621-1937
Practice Address - Country:US
Practice Address - Phone:510-409-7098
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility