Healthcare Provider Details

I. General information

NPI: 1447224381
Provider Name (Legal Business Name): OUR LADY OF GUADALUPE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1474 N 5TH ST
PORT HUENEME CA
93041-2205
US

IV. Provider business mailing address

2311 E CHEVY CHASE DR
GLENDALE CA
91206-1811
US

V. Phone/Fax

Practice location:
  • Phone: 805-487-9757
  • Fax: 805-487-9757
Mailing address:
  • Phone: 805-487-9757
  • Fax: 805-487-9757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number StateCA

VIII. Authorized Official

Name: MS. NORMA VELASCO
Title or Position: OWNER
Credential: PRESIDENT
Phone: 805-487-9757