Healthcare Provider Details

I. General information

NPI: 1912357120
Provider Name (Legal Business Name): ANGELS ASSISTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2016
Last Update Date: 06/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8024 REDWOOD AVE
FONTANA CA
92336-1640
US

IV. Provider business mailing address

16627 CANYON LAKE LN
FONTANA CA
92336-1239
US

V. Phone/Fax

Practice location:
  • Phone: 909-371-3966
  • Fax: 909-371-3967
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MRS. AMELIA D ALADIN
Title or Position: PRESIDENT
Credential:
Phone: 909-532-3623