Healthcare Provider Details

I. General information

NPI: 1366934663
Provider Name (Legal Business Name): ROYAL CONGREGATE LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 11/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7354 DE SOTO AVE
CANOGA PARK CA
91303-1703
US

IV. Provider business mailing address

5530 CORBIN AVE STE 112
TARZANA CA
91356-6048
US

V. Phone/Fax

Practice location:
  • Phone: 818-657-7309
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JOSIE STA MARIA
Title or Position: PRESIDENT
Credential:
Phone: 818-456-2464