Healthcare Provider Details

I. General information

NPI: 1457715179
Provider Name (Legal Business Name): BEVERLY GLEN CONGREGATE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 NORTH BEVERLY GLEN BLVD.
BEL AIR CA
90077
US

IV. Provider business mailing address

1200 NORTH BEVERLY GLEN BLVD.
BEL AIR CA
90077
US

V. Phone/Fax

Practice location:
  • Phone: 424-371-5060
  • Fax: 424-371-5060
Mailing address:
  • Phone: 424-371-5060
  • Fax: 424-371-5060

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: VIKTORIA MICHELLE KIRAKOSIAN
Title or Position: OWNER
Credential:
Phone: 310-309-0959