MEDICARE: NORTH LAKE VILLAS 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	310400000X	Assisted Living Facility	197603823	CA

General Provider Information

NPI Number	:	1215191358
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH LAKE VILLAS INC.

Provider Business Mailing Address
First Line	:	2851 N LAKE AVE
Second Line	:
City	:	ALTADENA
State	:	CA
Zip	:	91001-1619
Country	:	US
Telephone Number	:	626-398-8668
Fax Number	:	626-398-7140

Provider Business Practice Location Address
First Line	:	2851 N LAKE AVE
Second Line	:
City	:	ALTADENA
State	:	CA
Zip	:	91001-1619
Country	:	US
Telephone Number	:	626-398-8668
Fax Number	:	626-398-7140

Authorized Official
Title or Position	:	OWNER
Name	:	NOURIT BRAUN
Credential	:
Telephone Number	:	626-398-8668

Provider Enumeration Date	:	07/17/2008
Last Update Date	:	07/17/2008

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