MEDICARE: PREMIERE COTTAGES 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

General Provider Information

NPI Number	:	1376072710
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIERE COTTAGES INC.

Provider Business Mailing Address
First Line	:	4815 PREMIERE AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808-1146
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4815 PREMIERE AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808
Country	:	US
Telephone Number	:	818-606-6136
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JOSE UMANA
Credential	:
Telephone Number	:	818-606-6136

Provider Enumeration Date	:	06/08/2017
Last Update Date	:	06/08/2017

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