Healthcare Provider Details

I. General information

NPI: 1548252620
Provider Name (Legal Business Name): GHC OF CANOGA PARK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 05/29/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22029 SATICOY ST
CANOGA PARK CA
91303-1133
US

IV. Provider business mailing address

22029 SATICOY ST
CANOGA PARK CA
91303-1133
US

V. Phone/Fax

Practice location:
  • Phone: 818-887-7050
  • Fax: 818-710-8219
Mailing address:
  • Phone: 818-887-7050
  • Fax: 818-710-8219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number920000014
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateCA

VIII. Authorized Official

Name: LOIS A MASTROCOLA
Title or Position: CFO
Credential:
Phone: 714-241-5600