Healthcare Provider Details

I. General information

NPI: 1407542707
Provider Name (Legal Business Name): PALOS VERDES CARE COTTAGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 PENINSULA VERDE DR
RANCHO PALOS VERDES CA
90275-1051
US

IV. Provider business mailing address

1808 PENINSULA VERDE DR
RANCHO PALOS VERDES CA
90275-1051
US

V. Phone/Fax

Practice location:
  • Phone: 562-356-7130
  • Fax:
Mailing address:
  • Phone: 562-356-7130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MA. SALVACION FABIANA MEDINA
Title or Position: CEO
Credential:
Phone: 562-356-7130