Healthcare Provider Details

I. General information

NPI: 1912371816
Provider Name (Legal Business Name): CASA CERRITOS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2015
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10802 ANDY ST
CERRITOS CA
90703-8064
US

IV. Provider business mailing address

10802 ANDY ST
CERRITOS CA
90703-8064
US

V. Phone/Fax

Practice location:
  • Phone: 562-225-2649
  • Fax:
Mailing address:
  • Phone: 562-225-2649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number198602141
License Number StateCA

VIII. Authorized Official

Name: TERESA SIATON MENDOZA
Title or Position: MEMBER
Credential: NP
Phone: 562-225-2649