MEDICARE: OUR LADY OF GUADALUPE

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		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447224381
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OUR LADY OF GUADALUPE

Provider Business Mailing Address
First Line	:	2311 E CHEVY CHASE DR
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91206-1811
Country	:	US
Telephone Number	:	805-487-9757
Fax Number	:	805-487-9757

Provider Business Practice Location Address
First Line	:	1474 N 5TH ST
Second Line	:
City	:	PORT HUENEME
State	:	CA
Zip	:	93041-2205
Country	:	US
Telephone Number	:	805-487-9757
Fax Number	:	805-487-9757

Authorized Official
Title or Position	:	OWNER
Name	:	MS. NORMA VELASCO
Credential	:	PRESIDENT
Telephone Number	:	805-487-9757

Provider Enumeration Date	:	02/15/2006
Last Update Date	:	08/22/2020

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Directions to “OUR LADY OF GUADALUPE ” Practice Location

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