Healthcare Provider Details

I. General information

NPI: 1518108950
Provider Name (Legal Business Name): BLUE HEAVEN HOSPICE & PALLIATIVE CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2009
Last Update Date: 04/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2117 LAKE AVE 102
ALTADENA CA
91001-2462
US

IV. Provider business mailing address

2117 LAKE AVE 102
ALTADENA CA
91001-2462
US

V. Phone/Fax

Practice location:
  • Phone: 626-628-0826
  • Fax: 626-628-0827
Mailing address:
  • Phone: 626-628-0826
  • Fax: 626-628-0827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateCA

VIII. Authorized Official

Name: MR. EDWARD JOUHARYAN I
Title or Position: ADMINISTRATOR
Credential:
Phone: 626-628-2826