Healthcare Provider Details

I. General information

NPI: 1154101954
Provider Name (Legal Business Name): HEARTLAND ADULT RESIDENTIAL FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2023
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1847 W 75TH ST
LOS ANGELES CA
90047-2323
US

IV. Provider business mailing address

1847 W 75TH ST
LOS ANGELES CA
90047-2323
US

V. Phone/Fax

Practice location:
  • Phone: 323-434-1404
  • Fax:
Mailing address:
  • Phone: 323-434-1404
  • 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 Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. NICOLE WILLIAMS
Title or Position: CEO
Credential:
Phone: 323-434-1404