MEDICARE: CARIDEAN, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility	960000880	CA

General Provider Information

NPI Number	:	1063621126
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARIDEAN, INC.

Provider Business Mailing Address
First Line	:	1948 THOREAU ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90047-4725
Country	:	US
Telephone Number	:	323-770-2051
Fax Number	:

Provider Business Practice Location Address
First Line	:	1942 THOREAU ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90047-4725
Country	:	US
Telephone Number	:	323-756-5138
Fax Number	:	323-779-3615

Authorized Official
Title or Position	:	LICENSEE
Name	:	CARRIE GRIFFIS
Credential	:
Telephone Number	:	323-770-2051

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	06/20/2008

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