Healthcare Provider Details

I. General information

NPI: 1790766376
Provider Name (Legal Business Name): CANYON PROPERTIES III, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11723 FENTON AVE
LAKE VIEW TERRACE CA
91342-6431
US

IV. Provider business mailing address

11723 FENTON AVE
LAKE VIEW TERRACE CA
91342-6431
US

V. Phone/Fax

Practice location:
  • Phone: 818-899-0251
  • Fax: 818-890-5400
Mailing address:
  • Phone: 818-899-0251
  • Fax: 818-890-5400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number920000026
License Number StateCA

VIII. Authorized Official

Name: MARCIA S WELDON
Title or Position: ADMINISTRATOR
Credential:
Phone: 818-899-0251