Healthcare Provider Details

I. General information

NPI: 1164269387
Provider Name (Legal Business Name): EXCEL RESIDENTIAL HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2024
Last Update Date: 07/15/2024
Certification Date: 07/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5503 S MANHATTAN PL
LOS ANGELES CA
90062-2622
US

IV. Provider business mailing address

5503 S MANHATTAN PL
LOS ANGELES CA
90062-2622
US

V. Phone/Fax

Practice location:
  • Phone: 213-369-1383
  • Fax:
Mailing address:
  • Phone: 213-369-1383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: MR. KENNETH WATTS
Title or Position: ADMINISTRATOR
Credential: ADMINISTRATOR
Phone: 213-369-1383