Healthcare Provider Details

I. General information

NPI: 1306245105
Provider Name (Legal Business Name): AV CONGREGATE LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2014
Last Update Date: 08/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4144 VAHAN CT
LANCASTER CA
93536-6838
US

IV. Provider business mailing address

4144 VAHAN COURT
LANCASTER CA
93536
US

V. Phone/Fax

Practice location:
  • Phone: 661-943-1262
  • Fax:
Mailing address:
  • Phone: 661-943-1262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: JERRICO REYES
Title or Position: PRESIDENT
Credential:
Phone: 661-943-1262