Healthcare Provider Details

I. General information

NPI: 1598936205
Provider Name (Legal Business Name): LEISURE VILLAGE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 03/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6726 GAVIOTA AVE
LAKE BALBOA CA
91406-5944
US

IV. Provider business mailing address

19528 VENTURA BLVD STE 660
TARZANA CA
91356-2917
US

V. Phone/Fax

Practice location:
  • Phone: 818-402-7867
  • Fax: 818-774-0563
Mailing address:
  • Phone: 818-386-8599
  • Fax: 818-774-0563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. KOKE AHANKOOB
Title or Position: PRESIDENT
Credential:
Phone: 818-402-7867