Healthcare Provider Details

I. General information

NPI: 1629560263
Provider Name (Legal Business Name): MCLENNAN AVENUE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12325 MCLENNAN AVE
GRANADA HILLS CA
91344-1716
US

IV. Provider business mailing address

12325 MCLENNAN AVE
GRANADA HILLS CA
91344-1716
US

V. Phone/Fax

Practice location:
  • Phone: 818-886-3172
  • Fax: 747-300-9108
Mailing address:
  • Phone: 818-886-3172
  • Fax: 747-300-9108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. ROY L MARTIN II
Title or Position: PRESIDENT
Credential:
Phone: 323-253-5316